The economic burden of maternal mortality on households: evidence from three sub-counties in rural western Kenya.

PubMed

Kes, Aslihan; Ogwang, Sheila; Pande, Rohini; Douglas, Zayid; Karuga, Robinson; Odhiambo, Frank O; Laserson, Kayla; Schaffer, Kathleen

2015-05-06

This study explores the consequences of a maternal death to households in rural Western Kenya focusing particularly on the immediate financial and economic impacts. Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy and health care access and utilization; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. The health service utilization costs associated with maternal deaths were significantly higher, due to more frequent service utilization as well as due to the higher cost of each visit suggesting more involved treatments and interventions were sought with these women. The already high costs incurred by cases during pregnancy were further increased during delivery and postpartum mainly a result of higher facility-based fees and expenses. Households who experienced a maternal death spent about one-third of their annual per capita consumption expenditure on healthcare access and use as opposed to at most 12% among households who had a health pregnancy and delivery. Funeral costs were often higher than the healthcare costs and altogether forced households to dis-save, liquidate assets and borrow money. What is more, the surviving members of the households had significant redistribution of labor and responsibilities to make up for the lost contributions of the deceased women. Kenya is in the process of instituting free maternity services in all public facilities. Effectively implemented, this policy can lift a major economic burden experienced by a very large number of household who seek maternal health services which can be catastrophic in complicated cases that result in maternal death. There needs to be further emphasis on insurance schemes that can support households through catastrophic health spending.

The economic burden of maternal mortality on households: evidence from three sub-counties in rural western Kenya

PubMed Central

2015-01-01

Background This study explores the consequences of a maternal death to households in rural Western Kenya focusing particularly on the immediate financial and economic impacts. Methods Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy and health care access and utilization; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. Results The health service utilization costs associated with maternal deaths were significantly higher, due to more frequent service utilization as well as due to the higher cost of each visit suggesting more involved treatments and interventions were sought with these women. The already high costs incurred by cases during pregnancy were further increased during delivery and postpartum mainly a result of higher facility-based fees and expenses. Households who experienced a maternal death spent about one-third of their annual per capita consumption expenditure on healthcare access and use as opposed to at most 12% among households who had a health pregnancy and delivery. Funeral costs were often higher than the healthcare costs and altogether forced households to dis-save, liquidate assets and borrow money. What is more, the surviving members of the households had significant redistribution of labor and responsibilities to make up for the lost contributions of the deceased women. Conclusion Kenya is in the process of instituting free maternity services in all public facilities. Effectively implemented, this policy can lift a major economic burden experienced by a very large number of household who seek maternal health services which can be catastrophic in complicated cases that result in maternal death. There needs to be further emphasis on insurance schemes that can support households through catastrophic health spending. PMID:26000953

A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africa.

PubMed

Herrick, Tara; Mvundura, Mercy; Burke, Thomas F; Abu-Haydar, Elizabeth

2017-11-13

Postpartum hemorrhage (PPH) is the leading cause of maternal deaths worldwide. This study sought to quantify the potential health impact (morbidity and mortality reductions) that a low-cost uterine balloon tamponade (UBT) could have on women suffering from uncontrolled PPH due to uterine atony in sub-Saharan Africa. The Maternal and Neonatal Directed Assessment of Technology (MANDATE) model was used to estimate maternal deaths, surgeries averted, and cases of severe anemia prevented through UBT use among women with PPH who receive a uterotonic drug but fail this therapy in a health facility. Estimates were generated for the year 2018. The main outcome measures were lives saved, surgeries averted, and severe anemia prevented. The base case model estimated that widespread use of a low-cost UBT in clinics and hospitals could save 6547 lives (an 11% reduction in maternal deaths), avert 10,823 surgeries, and prevent 634 severe anemia cases in sub-Saharan Africa annually. A low-cost UBT has a strong potential to save lives and reduce morbidity. It can also potentially reduce costly downstream interventions for women who give birth in a health care facility. This technology may be especially useful for meeting global targets for reducing maternal mortality as identified in Sustainable Development Goal 3.

Maternal near-miss: a multicenter surveillance in Kathmandu Valley.

PubMed

Rana, Ashma; Baral, Gehanath; Dangal, Ganesh

2013-01-01

Multicenter surveillance has been carried out on maternal near-miss in the hospitals with sentinel units. Near-miss is recognized as the predictor of level of care and maternal death. Reducing Maternal Mortality Ratio is one of the challenges to achieve Millennium Development Goal. The objective was to determine the frequency and the nature of near-miss events and to analyze the near-miss morbidities among pregnant women. A prospective surveillance was done for a year in 2012 at nine hospitals in Kathmandu valley. Cases eligible by definition were recorded as a census based on WHO near-miss guideline. Similar questionnaires and dummy tables were used to present the results by non-inferential statistics. Out of 157 cases identified with near-miss rate of 3.8 per 1000 live births, severe complications were postpartum hemorrhage 62 (40%) and preeclampsia-eclampsia 25 (17%). Blood transfusion 102 (65%), ICU admission 85 (54%) and surgery 53 (32%) were common critical interventions. Oxytocin was main uterotonic used both prophylactically and therapeutically at health facilities. Total of 30 (19%) cases arrived at health facility after delivery or abortion. MgSO4 was used in all cases of eclampsia. All laparotomies were performed within three hours of arrival. Near-miss to maternal death ratio was 6:1 and MMR was 62. Study result yielded similar pattern amongst developing countries and same near-miss conditions as the causes of maternal death reported by national statistics. Process indicators qualified the recommended standard of care. The near-miss event could be used as a surrogate marker of maternal death and a window for system level intervention.

Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis.

PubMed

Goldie, Sue J; Sweet, Steve; Carvalho, Natalie; Natchu, Uma Chandra Mouli; Hu, Delphine

2010-04-20

Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India. Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold ( approximately 23%-35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately prevent four of five maternal deaths; this approach coupled stepwise improvements in family planning and safe abortion with consecutively implemented strategies that incrementally increased skilled attendants, improved antenatal/postpartum care, shifted births away from home, and improved recognition of referral need, transport, and availability/quality of EmOC. The strategies in this approach ranged from being cost-saving to having incremental cost-effectiveness ratios less than US$500 per year of life saved (YLS), well below India's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness. Early intensive efforts to improve family planning and control of fertility choices and to provide safe abortion, accompanied by a paced systematic and stepwise effort to scale up capacity for integrated maternal health services over several years, is as cost-effective as childhood immunization or treatment of malaria, tuberculosis, or HIV. In just 5 y, more than 150,000 maternal deaths would be averted through increasing contraception rates to meet women's needs for spacing and limiting births; nearly US$1.5 billion would be saved by coupling safe abortion to aggressive family planning efforts; and with stepwise investments to improve access to pregnancy-related health services and to high-quality facility-based intrapartum care, more than 75% of maternal deaths could be prevented. If accomplished over the next decade, the lives of more than one million women would be saved.

‘We identify, discuss, act and promise to prevent similar deaths’: a qualitative study of Ethiopia's Maternal Death Surveillance and Response system

PubMed Central

Abebe, Berhanu; Busza, Joanna; Hadush, Azmach; Usmael, Abdurehman; Zeleke, Amsalu Belew; Sita, Sahle; Hailu, Solomon; Graham, Wendy J

2017-01-01

Introduction Ethiopia introduced national Maternal Death Surveillance and Response (MDSR) in 2013 and is among the first sub-Saharan African countries to capture data on facility-based and community-based maternal deaths. We interviewed frontline MDSR implementers about their experiences of the first 2 years of MDSR, including perceptions of its introduction and outcomes for health services. Methods We conducted a qualitative case study in 4 zones in the largest regions, interviewing 69 key informants from regional, zonal, district and facility levels. Results A defining feature of Ethiopia's MDSR system is its integration within existing disease surveillance, with both benefits and challenges. Facilitators of the system's introduction were strong political support, alignment with broader health strategies and strong links across health system departments. Barriers included confusion around new responsibilities, high staff turnover and fear of legal repercussions. Stakeholders believed MDSR increased confidence in using local data to improve maternal health services and enhanced communication across the health system. Conclusions MDSR systems take time to establish, encountering challenges in early implementation. Ensuring MDSR has a clear purpose, explicitly defined roles and responsibilities, and adequate supervisory support from the start will ensure it becomes embedded within the health system as routine practice rather than perceived as a stand-alone system. Countries planning to adopt or extend MDSR can learn from Ethiopia's experience, particularly the decision to make maternal mortality a weekly reportable condition within Public Health Emergency Management. PMID:28589016

Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal.

PubMed

Lama, Tsering P; Khatry, Subarna K; Katz, Joanne; LeClerq, Steven C; Mullany, Luke C

2017-12-21

Identification of maternal and newborn illness and the decision-making and subsequent care-seeking patterns are poorly understood in Nepal. We aimed to characterize the process and factors influencing recognition of complications, the decision-making process, and care-seeking behavior among families and communities who experienced a maternal complication, death, neonatal illness, or death in a rural setting of Nepal. Thirty-two event narratives (six maternal/newborn deaths each and 10 maternal/newborn illnesses each) were collected using in-depth interviews and small group interviews. We purposively sampled across specific illness and complication definitions, using data collected prospectively from a cohort of women and newborns followed from pregnancy through the first 28 days postpartum. The event narratives were coded and analyzed for common themes corresponding to three main domains of illness recognition, decision-making, and care-seeking; detailed event timelines were created for each. While signs were typically recognized early, delays in perceiving the severity of illness compromised prompt care-seeking in both maternal and newborn cases. Further, care was often sought initially from informal health providers such as traditional birth attendants, traditional healers, and village doctors. Key decision-makers were usually female family members; husbands played limited roles in decisions related to care-seeking, with broader family involvement in decision-making for newborns. Barriers to seeking care at any type of health facility included transport problems, lack of money, night-time illness events, low perceived severity, and distance to facility. Facility care was often sought only after referral or following treatment failure from an informal provider and private facilities were sought for newborn care. Respondents characterized government facility-based care as low quality and reported staff rudeness and drug type and/or supply stock shortages. Delaying the decision to seek skilled care was common in both newborn and maternal cases. Among maternal cases, delays in receiving appropriate care when at a facility were also seen. Improved recognition of danger signs and increased demand for skilled care, motivated through community level interventions and health worker mobilization, needs to be encouraged. Engaging informal providers through training in improved danger sign identification and prompt referral, especially for newborn illnesses, is recommended.

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

PubMed

D'Alton, Mary E; Friedman, Alexander M; Smiley, Richard M; Montgomery, Douglas M; Paidas, Michael J; D'Oria, Robyn; Frost, Jennifer L; Hameed, Afshan B; Karsnitz, Deborah; Levy, Barbara S; Clark, Steven L

2016-10-01

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

A systems approach to improving maternal health in the Philippines

PubMed Central

Banzon, Eduardo; Recidoro, Zenaida Dy

2012-01-01

Abstract Objective To examine the impact of health-system-wide improvements on maternal health outcomes in the Philippines. Methods A retrospective longitudinal controlled study was used to compare a province that fast tracked the implementation of health system reforms with other provinces in the same region that introduced reforms less systematically and intensively between 2006 and 2009. Findings The early reform province quickly upgraded facilities in the tertiary and first level referral hospitals; other provinces had just begun reforms by the end of the study period. The early reform province had created 871 women’s health teams by the end of 2009, compared with 391 teams in the only other province that reported such teams. The amount of maternal-health-care benefits paid by the Philippine Health Insurance Corporation in the early reform province grew by approximately 45%; in the other provinces, the next largest increase was 16%. The facility-based delivery rate increased by 44 percentage points in the early reform province, compared with 9–24 percentage points in the other provinces. Between 2006 and 2009, the actual number of maternal deaths in the early reform province fell from 42 to 18, and the maternal mortality ratio from 254 to 114. Smaller declines in maternal deaths over this period were seen in Camarines Norte (from 12 to 11) and Camarines Sur (from 26­ to 23). The remaining three provinces reported increases in maternal deaths. Conclusion Making health-system-wide reforms to improve maternal health has positive synergistic effects. PMID:22423161

Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis

PubMed Central

Goldie, Sue J.; Sweet, Steve; Carvalho, Natalie; Natchu, Uma Chandra Mouli; Hu, Delphine

2010-01-01

Background Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India. Methods and Findings Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold (∼23%–35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately prevent four of five maternal deaths; this approach coupled stepwise improvements in family planning and safe abortion with consecutively implemented strategies that incrementally increased skilled attendants, improved antenatal/postpartum care, shifted births away from home, and improved recognition of referral need, transport, and availability/quality of EmOC. The strategies in this approach ranged from being cost-saving to having incremental cost-effectiveness ratios less than US$500 per year of life saved (YLS), well below India's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness. Conclusions Early intensive efforts to improve family planning and control of fertility choices and to provide safe abortion, accompanied by a paced systematic and stepwise effort to scale up capacity for integrated maternal health services over several years, is as cost-effective as childhood immunization or treatment of malaria, tuberculosis, or HIV. In just 5 y, more than 150,000 maternal deaths would be averted through increasing contraception rates to meet women's needs for spacing and limiting births; nearly US$1.5 billion would be saved by coupling safe abortion to aggressive family planning efforts; and with stepwise investments to improve access to pregnancy-related health services and to high-quality facility-based intrapartum care, more than 75% of maternal deaths could be prevented. If accomplished over the next decade, the lives of more than one million women would be saved. Please see later in the article for the Editors' Summary PMID:20421922

A study on maternal mortality in Mexico through a qualitative approach.

PubMed

Castro, R; Campero, L; Hernández, B; Langer, A

2000-01-01

This report presents the main qualitative results of a verbal autopsy study carried out in three states of Mexico, which aimed at identifying the factors associated with maternal mortality that could be subject to modifications through concrete interventions. By reviewing death certificates issued in 1995, it was possible to identify 164 households where a maternal death had occurred. One hundred forty-five of these households were visited, and a precoded questionnaire was completed to explore socioeconomic and living conditions, as well as causes of death. An open-ended question to prompt the relatives to narrate all the facts that led to the maternal deaths was included in the questionnaire. This study presents an analysis of that question, focusing on the delays in the care-seeking process and organized according to the model of the three delays: in deciding to seek care, in reaching a care facility, and in actually receiving care after arrival. Additionally, problems related to quality of care are examined. For analysis of the accounts, structural, interactional/community, and subjective variables were identified that allowed refining of our understanding of the problem of maternal deaths. Finally, based on the findings of the study, this article presents a series of recommendations, highlighting that interventions should address the early stages of a complication and focus on decreasing the various forms of inequality (gender and socioeconomic) associated with the occurrence of maternal deaths.

Availability and utilization of obstetric and newborn care in Guinea: A national needs assessment.

PubMed

Baguiya, Adama; Meda, Ivlabèhiré Bertrand; Millogo, Tieba; Kourouma, Mamadou; Mouniri, Halima; Kouanda, Seni

2016-11-01

To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) in Guinea given the high maternal and neonatal mortality rates. We used the Guinea 2012 needs assessment data collected via a national cross-sectional census of health facilities conducted from September to October 2012. All public, private, and faith-based health facilities that performed at least one delivery during the period of the study were included. A total of 502 health facilities were visited, of which 81 were hospitals. Only 15 facilities were classified as fully functioning EmONC facilities, all of which were reference hospitals. None of the first level health facilities were fully functioning EmONC facilities. The ratio of availability of EmONC was one fully functioning EmONC facility for 745 415 inhabitants. The institutional delivery rate was 32.3% and the proportion of all births in EmONC facilities was 7.1%. Met need for EmONC was 12.2%. Among 201 maternal deaths in EmONC facilities, 69 were due to indirect causes. The intrapartum and very early neonatal death rate was 39 deaths per 1000 live births. The study showed low availability of EmONC services and underutilization of the available services. Further investigation is needed to evaluate the effect of the current policy of user fees exemption for deliveries and prenatal care in Guinea. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

'Safe', yet violent? Women's experiences with obstetric violence during hospital births in rural Northeast India.

PubMed

Chattopadhyay, Sreeparna; Mishra, Arima; Jacob, Suraj

2017-11-03

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance.

The fourth delay and community-driven solutions to reduce maternal mortality in rural Haiti: a community-based action research study.

PubMed

MacDonald, Tonya; Jackson, Suzanne; Charles, Marie-Carmèle; Periel, Marius; Jean-Baptiste, Marie-Véna; Salomon, Alex; Premilus, Éveillard

2018-06-20

In Haiti, the number of women dying in pregnancy, during childbirth and the weeks after giving birth remains unacceptably high. The objective of this research was to explore determinants of maternal mortality in rural Haiti through Community-Based Action Research (CBAR), guided by the delays that lead to maternal death. This paper focuses on socioecological determinants of maternal mortality from the perspectives of women of near-miss maternal experiences and community members, and their solutions to reduce maternal mortality in their community. The study draws on five semi-structured Individual Interviews with women survivors of near-misses, and on four Focus Group Discussions with Community Leaders and with Traditional Birth Attendants. Data collection took place in July 2013. A Community Research Team within a resource-limited rural community in Haiti undertook the research. The methods and analysis process were guided by participatory research and CBAR. Participants identified three delays that lead to maternal death but also described a fourth delay with respect to community responsibility for maternal mortality. They included women being carried from the community to a healthcare facility as a special example of the fourth delay. Women survivors of near-miss maternal experiences and community leaders suggested solutions to reduce maternal death that centered on prevention and community infrastructure. Most of the strategies for action were related to the fourth delay and include: community mobilization by way of the formation of Neighbourhood Maternal Health/Well-being Committees, and community support through the provision/sharing of food for undernourished women, offering monetary support and establishment of a communication relay/transport system in times of crisis. Finding sustainable ways to reduce maternal mortality requires a community-based/centred and community-driven comprehensive approach to maternal health/well-being. This includes engagement of community members that is dependent upon community knowledge, political will, mobilization, accountability and empowerment. An engaged/empowered community is one that is well placed to find ways that work in their community to reduce the fourth delay and in turn, maternal death. Potentially, community ownership of challenges and solutions can lead to more sustainable improvements in maternal health/well-being in Haiti.

Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies.

PubMed

Chinkhumba, Jobiba; De Allegri, Manuela; Muula, Adamson S; Robberstad, Bjarne

2014-09-28

Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa. We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals. We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction. Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.

Impact of Facility- and Community-Based Peer Support Models on Maternal Uptake and Retention in Malawi's Option B+ HIV Prevention of Mother-to-Child Transmission Program: A 3-Arm Cluster Randomized Controlled Trial (PURE Malawi).

PubMed

Phiri, Sam; Tweya, Hannock; van Lettow, Monique; Rosenberg, Nora E; Trapence, Clement; Kapito-Tembo, Atupele; Kaunda-Khangamwa, Blessings; Kasende, Florence; Kayoyo, Virginia; Cataldo, Fabian; Stanley, Christopher; Gugsa, Salem; Sampathkumar, Veena; Schouten, Erik; Chiwaula, Levison; Eliya, Michael; Chimbwandira, Frank; Hosseinipour, Mina C

2017-06-01

Many sub-Saharan African countries have adopted Option B+, a prevention of mother-to-child transmission approach providing HIV-infected pregnant and lactating women with immediate lifelong antiretroviral therapy. High maternal attrition has been observed in Option B+. Peer-based support may improve retention. A 3-arm stratified cluster randomized controlled trial was conducted in Malawi to assess whether facility- and community-based peer support would improve Option B+ uptake and retention compared with standard of care (SOC). In SOC, no enhancements were made (control). In facility-based and community-based models, peers provided patient education, support groups, and patient tracing. Uptake was defined as attending a second scheduled follow-up visit. Retention was defined as being alive and in-care at 2 years without defaulting. Attrition was defined as death, default, or stopping antiretroviral therapy. Generalized estimating equations were used to estimate risk differences (RDs) in uptake. Cox proportional hazards regression with shared frailties was used to estimate hazard of attrition. Twenty-one facilities were randomized and enrolled 1269 women: 447, 428, and 394 in facilities that implemented SOC, facility-based, and community-based peer support models, respectively. Mean age was 27 years. Uptake was higher in facility-based (86%; RD: 6%, confidence interval [CI]: -3% to 15%) and community-based (90%; RD: 9%, CI: 1% to 18%) models compared with SOC (81%). At 24 months, retention was higher in facility-based (80%; RD: 13%, CI: 1% to 26%) and community-based (83%; RD: 16%, CI: 3% to 30%) models compared with SOC (66%). Facility- and community-based peer support interventions can benefit maternal uptake and retention in Option B+.

Approaches to improve the quality of maternal and newborn health care: an overview of the evidence.

PubMed

Austin, Anne; Langer, Ana; Salam, Rehana A; Lassi, Zohra S; Das, Jai K; Bhutta, Zulfiqar A

2014-09-04

Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. In addition, women who perceive the quality of facilty-based care to be poor,may choose to avoid facility-based deliveries, where life-saving interventions could be availble. In this context, understanding the underlying factors that impact the quality of facility-based services and assessing the effectiveness of interventions to improve the quality of care represent critical inputs for the improvement of maternal and newborn health. This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. The first paper outlines the conceptual framework that guided this study and the methodology used for selecting the reviews and for the analysis. The results are described in the following three papers, which highlight the evidence of interventions to improve the quality of maternal and newborn care at the community, district, and facility level. In the fifth and final paper of the series, the overall findings of the review are discussed, research gaps are identified, and recommendations proposed to impove the quality of maternal and newborn health care in resource-poor settings.

Professional responsibility in maternity care: role of medical audit.

PubMed

Bhatt, R V

1989-09-01

In 1965, Baroda Medical College initiated a process of medical audit of maternal and perinatal deaths occurring at this institution, and consultation in peripheral medical facilities providing antenatal and obstetric care. By 1984 maternal and perinatal mortality had declined and clinical judgment in maternity care had improved.

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

PubMed

van Dillen, Jeroen; Stekelenburg, Jelle; Schutte, Joke; Walraven, Gijs; van Roosmalen, Jos

2007-01-01

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths. Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries. Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and the Netherlands. Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from the Netherlands. Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in the Netherlands. Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics. MMR ranged from 10 per 100,000 (the Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia. Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and Lessons Learned

PubMed Central

Smith, Helen; Ameh, Charles; Godia, Pamela; Maua, Judith; Bartilol, Kigen; Amoth, Patrick; Mathai, Matthews; van den Broek, Nynke

2017-01-01

ABSTRACT Maternal death surveillance and response (MDSR) constitutes a quality improvement approach to identify how many maternal deaths occur, what the underlying causes of death and associated factors are, and how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths. This requires a coordinated approach, ensuring both national- and district-level stakeholders are enabled and supported and can implement MDSR in a “no name, no blame” environment. This field action report from Kenya provides an example of how MDSR can be implemented in a “real-life” setting by summarizing the experiences and challenges faced thus far by maternal death assessors and Ministry of Health representatives in implementing MDSR. Strong national leadership via a coordinating secretariat has worked well in Kenya. However, several challenges were encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. To ensure progress toward a full national enquiry of all maternal deaths, we recommend improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting. Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system. Perinatal death surveillance and response is planned as a next phase of MDSR implementation in Kenya. To ensure the process continues to evolve into a full national enquiry of all maternal deaths, we recommend securing longer-term budget allocation and financial commitment from the ministry, securing a national legal framework for MDSR, and improving processes at the subnational level. PMID:28963171

Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study

PubMed Central

2010-01-01

Background Investigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities. Methods Retrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions. Results There were 28 025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100 000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU). Conclusion Near-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post-partum haemorrhage and training health care professionals to manage infrequent but fatal conditions like sepsis. An urgent review of the referral system and the emergency obstetric care in Syria is highly recommended. PMID:20959012

Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model

PubMed Central

Nyamtema, Angelo S.; Mwakatundu, Nguke; Dominico, Sunday; Mohamed, Hamed; Pemba, Senga; Rumanyika, Richard; Kairuki, Clementina; Kassiga, Irene; Shayo, Allan; Issa, Omary; Nzabuhakwa, Calist; Lyimo, Chagi; van Roosmalen, Jos

2016-01-01

Background In Tanzania, maternal mortality ratio (MMR), unmet need for emergency obstetric care and health inequities across the country are in a critical state, particularly in rural areas. This study was established to determine the feasibility and impact of decentralizing comprehensive emergency obstetric and neonatal care (CEmONC) services in underserved rural areas using associate clinicians. Methods Ten health centres (HCs) were upgraded by constructing and equipping maternity blocks, operating rooms, laboratories, staff houses and installing solar panels, standby generators and water supply systems. Twenty-three assistant medical officers (advanced level associate clinicians), and forty-four nurse-midwives and clinical officers (associate clinicians) were trained in CEmONC and anaesthesia respectively. CEmONC services were launched between 2009 and 2012. Monthly supportive supervision and clinical audits of adverse pregnancy outcomes were introduced in 2011 in these HCs and their respective district hospitals. Findings After launching CEmONC services from 2009 to 2014 institutional deliveries increased in all upgraded rural HCs. Mean numbers of monthly deliveries increased by 151% and obstetric referrals decreased from 9% to 3% (p = 0.03) in HCs. A total of 43,846 deliveries and 2,890 caesarean sections (CS) were performed in these HCs making the mean proportion of all births in EmONC facilities of 128% and mean population-based CS rate of 9%. There were 190 maternal deaths and 1,198 intrapartum and very early neonatal deaths (IVEND) in all health facilities. Generally, health centres had statistically significantly lower maternal mortality ratios and IVEND rates than district hospitals (p < 0.00 and < 0.02 respectively). Of all deaths (maternal and IVEND) 84% to 96% were considered avoidable. Conclusions These findings strongly indicate that remotely located health centres in resource limited settings hold a great potential to increase accessibility to CEmONC services and to improve maternal and perinatal health. PMID:26986725

Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model.

PubMed

Nyamtema, Angelo S; Mwakatundu, Nguke; Dominico, Sunday; Mohamed, Hamed; Pemba, Senga; Rumanyika, Richard; Kairuki, Clementina; Kassiga, Irene; Shayo, Allan; Issa, Omary; Nzabuhakwa, Calist; Lyimo, Chagi; van Roosmalen, Jos

2016-01-01

In Tanzania, maternal mortality ratio (MMR), unmet need for emergency obstetric care and health inequities across the country are in a critical state, particularly in rural areas. This study was established to determine the feasibility and impact of decentralizing comprehensive emergency obstetric and neonatal care (CEmONC) services in underserved rural areas using associate clinicians. Ten health centres (HCs) were upgraded by constructing and equipping maternity blocks, operating rooms, laboratories, staff houses and installing solar panels, standby generators and water supply systems. Twenty-three assistant medical officers (advanced level associate clinicians), and forty-four nurse-midwives and clinical officers (associate clinicians) were trained in CEmONC and anaesthesia respectively. CEmONC services were launched between 2009 and 2012. Monthly supportive supervision and clinical audits of adverse pregnancy outcomes were introduced in 2011 in these HCs and their respective district hospitals. After launching CEmONC services from 2009 to 2014 institutional deliveries increased in all upgraded rural HCs. Mean numbers of monthly deliveries increased by 151% and obstetric referrals decreased from 9% to 3% (p = 0.03) in HCs. A total of 43,846 deliveries and 2,890 caesarean sections (CS) were performed in these HCs making the mean proportion of all births in EmONC facilities of 128% and mean population-based CS rate of 9%. There were 190 maternal deaths and 1,198 intrapartum and very early neonatal deaths (IVEND) in all health facilities. Generally, health centres had statistically significantly lower maternal mortality ratios and IVEND rates than district hospitals (p < 0.00 and < 0.02 respectively). Of all deaths (maternal and IVEND) 84% to 96% were considered avoidable. These findings strongly indicate that remotely located health centres in resource limited settings hold a great potential to increase accessibility to CEmONC services and to improve maternal and perinatal health.

Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities.

PubMed

Main, Elliott K; McCain, Christy L; Morton, Christine H; Holtby, Susan; Lawton, Elizabeth S

2015-04-01

To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs. California pregnancy-related deaths from 2002-2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population. Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death. Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.

Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India.

PubMed

Halder, Ajay; Jose, Ruby; Vijayselvi, Reeta

2014-01-01

Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level. This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10(th) Revision was used to define and classify maternal mortality. There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two- and 38.52% had four- or more organ involvement. The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.

Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey.

PubMed

Tunçalp, Ö; Souza, J P; Hindin, M J; Santos, C A; Oliveira, T H; Vogel, J P; Togoobaatar, G; Ha, D Q; Say, L; Gülmezoglu, A M

2014-03-01

To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities. Cross-sectional study. Twenty-nine countries in Africa, Asia, Latin America, and the Middle East. Pregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011. Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed. Severe maternal outcomes (near misses and death). A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05). Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Empowering members of a rural southern community in Nigeria to plan to take action to prevent maternal mortality: A participatory action research project.

PubMed

Esienumoh, Ekpoanwan E; Allotey, Janette; Waterman, Heather

2018-04-01

To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilisation. In this article, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Participatory action research was used. Twelve volunteers were recruited as coresearchers into the study through purposive and snowball sampling who, following an orientation workshop, undertook participatory qualitative data collection with an additional 29 community members. Participatory thematic analysis of the data was undertaken which formed the basis of the plan of action. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through community education and advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. The community is a resource which if mobilised through the process of participatory action research can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Interventions to prevent maternal deaths should include community empowerment to have better understanding of their circumstances as well as their collaboration with health professionals. © 2018 John Wiley & Sons Ltd.

The Economic Cost of Implementing Maternal and Neonatal Death Review in a District of Bangladesh.

PubMed

Biswas, Animesh; Halim, Abdul; Rahman, Fazlur; Eriksson, Charli; Dalal, Koustuv

2016-12-09

Maternal and neonatal death review (MNDR) introduced in Bangladesh and initially piloted in a district during 2010. MNDR is able to capture each of the maternal, neonatal deaths and stillbirths from the community and government facilities (hospitals). This study aimed to estimate the cost required to implement MNDR in a district of Bangladesh during 2010-2012. MNDR was implemented in Thakurgaon district in 2010 and later gradually extended until 2015. MNDR implementation framework, guidelines, tools and manual were developed at the national level with national level stakeholders including government health and family planning staff at different cadre for piloting at Thakurgaon. Programme implementation costs were calculated by year of costing and costing as per component of MNDR in 2013. The purchasing power parity conversion rate was 1 $INT = 24.46 BDT, as of 31 st Dec 2012. Overall programme implementation costs required to run MNDR were 109,02,754 BDT (445,738 $INT $INT) in the first year (2010). In the following years cost reduced to 8,208,995 BDT (335,609 $INT, during 2011) and 6,622,166 BDT (270,735 $INT, during 2012). The average cost per activity required was 3070 BDT in 2010, 1887 BDT and 2207 BDT required in 2011 and 2012 respectively. Each death notification cost 4.09 $INT, verbal autopsy cost 8.18 $INT, and social autopsy cost 16.35 $INT. Facility death notification cost 2.04 $INT and facility death review meetings cost 20.44 $INT. One death saved by MNDR costs 53,654 BDT (2193 $INT). Programmatic implementation cost of conducting MPDR give an idea on how much cost will be required to run a death review system for a low income country settings using government health system.

Maternal sociodemographic characteristics and risk factors of antepartum fetal death.

PubMed

Azim, M A; Sultana, N; Chowdhury, S; Azim, E

2012-04-01

The objectives of this study were to assess the sociodemographic profile and to identify the risk factors of ante-partum fetal death which occurs after the age of viability of fetus. This prospective observational study was conducted in the Obstetrics department of Ad-din Women Medical College Hospital during the period of June, 2009 to July, 2010. A total of 14,015 pregnant patients were admitted in the study place after the age of viability, which was taken as 28 weeks of gestation for our facilities. Eighty-three (0.59%) of them were identified as intrauterine fetal death. Assessment of maternal sociodemographic characteristics and maternal-fetal risk factors were evaluated with a semi structured questionnaire pretested. Majority (81.92%, n=68) of the patients were below 30 years of age, 78.31% belonged to middle socioeconomic group. Almost 58% women had education below SSC level and 28.91% took regular antenatal checkup. About 61.45% patients were multigravida. Most (59.04%) ante-partum deaths were identified below 32 weeks of pregnancy. Out of 83 patients, maternal risk factors were identified in 41(49.59%) cases where fetal risk factors were found in 16(19.27%) cases; no risk factors could be determined in rests. Hypertension (48.78%), diabetes (21.95%), hyperpyrexia (17.3%), abruptio placentae (4.88%) and UTI (7.36%) were identified as maternal factors; and congenital anomaly (37.5%), Rh incompatibility (37.5%), multiple pregnancy (12.5%) and post-maturity (12.5%) were the fetal risk factors. Here, proximal biological risk factors are most important in ante-partum fetal deaths. More investigations and facilities are needed to explain the causes of antepartum deaths.

Janani Suraksha Yojana: the conditional cash transfer scheme to reduce maternal mortality in India - a need for reassessment.

PubMed

Rai, Rajesh Kumar; Singh, Prashant Kumar

2012-01-01

Alongside endorsing Millennium Development Goal 5 in 2000, India launched its National Population Policy in 2000 and the National Health Policy in 2002. However, these have failed thus far to reduce the maternal mortality ratio (MMR) by the targeted 5.5% per annum. Under the banner of the National Rural Health Mission, the Government of India launched a national conditional cash transfer (CCT) scheme in 2005 called Janani Suraksha Yojana (JSY), aimed to encourage women to give birth in health facilities which, in turn, should reduce maternal deaths. Poor prenatal care in general, and postnatal care in particular, could be considered the causes of the high number of maternal deaths in India (the highest in the world). Undoubtedly, institutional delivery in India has increased and MMR has reduced over time as a result of socioeconomic development coupled with advancement in health care including improved women's education, awareness and availability of health services. However, in the light of its performance, we argue that the JSY scheme was not well enough designed to be considered as an effective pathway to reduce MMR. We propose that the service-based CCT is not the solution to avoid/reduce maternal deaths and that policy-makers and programme managers should reconsider the 'package' of continuum of care and maternal health services to ensure that they start from adolescence and the pre-pregnancy period, and extend to delivery, postnatal and continued maternal health care.

Family planning issues relating to maternal and infant mortality in the United States.

PubMed

Puffer, R R

1993-01-01

Both maternal and infant death rates in the United States are much higher than in many developed countries. The interrelationships between abortions and maternal and infant mortality have been analyzed on the basis of data from the 1970s and 1980s. The legalization of abortions in 1973 resulted in a marked increase in legal abortions and marked reductions in maternal and infant mortality over the course of the 1970s. However, a wide variation in abortion rates and in the number of abortion facilities indicates that such facilities were not readily available to all segments of the population in some areas. This probably accounts in part for higher maternal and infant death rates in such areas. Smoking, small weight gain, use of alcohol and drugs in pregnancy, and excessive maternal youth or age affected the outcome of pregnancy and contributed to high rates of infant death. Infant death rates were especially high among newborns of teenagers and young adult mothers; relatively high proportions of these newborns had low birthweights; a large share of the pregnancies involved were unintended; and slightly over half of the unintended pregnancies in teenagers and young women resulted in abortion. Comparisons with findings in Sweden reveal that the rates of unplanned pregnancy, abortion, and infant mortality were all much higher in the United States than in Sweden. The differences are attributed to better contraceptive services, which were made available free or very inexpensively in Sweden. Also, the frequency of low weight births was much lower in Sweden.

Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5.

PubMed

Shah, Pankaj; Shah, Shobha; Kutty, Raman V; Modi, Dhiren

2014-05-01

To understand changes in epidemiology of maternal mortality in rural India in the context of increasing institutional deliveries and implementation of community-based interventions that can inform policies to reach MDG-5. This study is a secondary analysis of prospectively collected community-based data of every pregnancy and its outcomes from 2002 to 2011 in a rural, tribal area of Gujarat, India as part of safe-motherhood programme implemented by voluntary organisation, SEWA Rural. The programme consisted of community-based interventions supported by a first referral unit, and promotion of institutional deliveries. For every maternal death, a verbal autopsy was conducted. The incidence rates for maternal mortality according to place, cause and timing of maternal deaths in relation to pregnancy were computed. Annual incidence rate ratios (IRR) and 95% confidence intervals, adjusted for caste and maternal education, were estimated using Poisson regression to test for linear trend in reduction in mortality during the study period. Thirty-two thousand eight hundred and ninety-three pregnancies, 29,817 live births and 80 maternal deaths were recorded. Maternal mortality ratio improved from 607 (19 deaths) in 2002-2003 to 161 (five deaths) in 2010-2011. The institutional delivery rate increased from 23% to 65%. The trend of falling maternal deaths was significant over time, with an annual reduction of 17% (adjusted IRR 0.83 CI 0.75-0.91, P-value <0.001). There were significant reductions in adjusted incidence rate of maternal deaths due to direct causes, during intrapartum and post-partum periods, and those which occurred at home. However, reductions in incidence of maternal deaths due to indirect causes, at hospital and during antepartum period were not statistically significant. Most maternal deaths are now occurring at hospitals and due to indirect causes. Gains in institutional deliveries and community-based interventions resulting in fewer maternal deaths due to direct causes should be maintained. However, it would be essential to now prioritize management of indirect causes of maternal mortality during pregnancy at community and hospitals for further reduction in maternal deaths to achieve MDG-5. © 2014 John Wiley & Sons Ltd.

What makes or mars the facility-based childbirth experience: thematic analysis of women's childbirth experiences in western Kenya.

PubMed

Afulani, Patience A; Kirumbi, Leah; Lyndon, Audrey

2017-12-29

Sub-Saharan Africa accounts for approximately 66% of global maternal deaths. Poor person-centered maternity care, which emphasizes the quality of patient experience, contributes both directly and indirectly to these poor outcomes. Yet, few studies in low resource settings have examined what is important to women during childbirth from their perspective. The aim of this study is to examine women's facility-based childbirth experiences in a rural county in Kenya, to identify aspects of care that contribute to a positive or negative birth experience. Data are from eight focus group discussions conducted in a rural county in western Kenya in October and November 2016, with 58 mothers aged 15 to 49 years who gave birth in the preceding nine weeks. We recorded and transcribed the discussions and used a thematic approach for data analysis. The findings suggest four factors influence women's perceptions of quality of care: responsiveness, supportive care, dignified care, and effective communication. Women had a positive experience when they were received well at the health facility, treated with kindness and respect, and given sufficient information about their care. The reverse led to a negative experience. These experiences were influenced by the behavior of both clinical and support staff and the facility environment. This study extends the literature on person-centered maternity care in low resource settings. To improve person-centered maternity care, interventions need to address the responsiveness of health facilities, ensure women receive supportive and dignified care, and promote effective patient-provider communication.

National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan.

PubMed

Carvalho, Natalie; Salehi, Ahmad Shah; Goldie, Sue J

2013-01-01

Afghanistan has one of the highest rates of maternal mortality in the world. We assess the health outcomes and cost-effectiveness of strategies to improve the safety of pregnancy and childbirth in Afghanistan. Using national and sub-national data, we adapted a previously validated model that simulates the natural history of pregnancy and pregnancy-related complications. We incorporated data on antenatal care, family planning, skilled birth attendance and information about access to transport, referral facilities and quality of care. We evaluated single interventions (e.g. family planning) and strategies that combined several interventions packaged as integrated services (transport, intrapartum care). Outcomes included pregnancy-related complications, maternal deaths, maternal mortality ratios, costs and cost-effectiveness ratios. Model-projected reduction in maternal deaths between 1999-2002 and 2007-08 approximated 20%. Increasing family planning was the most effective individual intervention to further reduce maternal mortality; up to 1 in 3 pregnancy-related deaths could be prevented if contraception use approached 60%. Nevertheless, reductions in maternal mortality reached a threshold (∼30% to 40%) without strategies that assured women access to emergency obstetrical care. A stepwise approach that coupled improved family planning with incremental improvements in skilled attendance, transport, referral and appropriate intrapartum care and high-quality facilities prevented 3 of 4 maternal deaths. Such an approach would cost less than US$200 per year of life saved at the national level, well below Afghanistan's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness. Similar results were noted sub-nationally. Our findings reinforce the importance of early intensive efforts to increase family planning for spacing and limiting births and to provide control of fertility choices. While significant improvements in health delivery infrastructure will be required to meet Millennium Development Goal 5, a paced systematic effort that invests in scaling up capacity for integrated maternal health services as the total fertility rate declines appears feasible and cost-effective.

A qualitative evaluation of the choice of traditional birth attendants for maternity care in 2008 Sierra Leone: implications for universal skilled attendance at delivery.

PubMed

Oyerinde, Koyejo; Harding, Yvonne; Amara, Philip; Garbrah-Aidoo, Nana; Kanu, Rugiatu; Oulare, Macoura; Shoo, Rumishael; Daoh, Kizito

2013-07-01

Maternal and newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities; and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.

The quality of the maternal health system in Eritrea.

PubMed

Sharan, Mona; Ahmed, Saifuddin; Ghebrehiwet, Mismay; Rogo, Khama

2011-12-01

To examine the quality of the maternal health system in Eritrea to understand system deficiencies and its relevance to maternal mortality within the context of Millennium Development Goal (MDG) 5. A sample of 118 health facilities was surveyed. Data were collected on 5 dimensions of health system quality: availability; accessibility; management; infrastructure; and process indicators. Data on the causes of hospital admissions for obstetric patients and maternal deaths were extracted from medical records. Eritrea has only 11 comprehensive emergency obstetric care (CEmOC) facilities, all of which are grossly understaffed. There is considerable pressure on the infrastructure and health providers at hospitals. Compliance with clinical care standards and availability of supplies were optimal. As a result, the case fatality rate of 0.65% was low. In total, 45.6% of obstetric admissions and 19.5% of maternal deaths were attributed to abortion complications. In Eritrea, critical gaps in the health system-especially those related to human resources-will impede progress toward MDG 5, and it will not be possible to reduce maternal mortality without addressing the high burden of abortion. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The state of emergency obstetric care services in Nairobi informal settlements and environs: Results from a maternity health facility survey

PubMed Central

Ziraba, Abdhalah K; Mills, Samuel; Madise, Nyovani; Saliku, Teresa; Fotso, Jean-Christophe

2009-01-01

Background Maternal mortality in Sub-Saharan Africa remains a challenge with estimates exceeding 1,000 maternal deaths per 100,000 live births in some countries. Successful prevention of maternal deaths hinges on adequate and quality emergency obstetric care. In addition to skilled personnel, there is need for a supportive environment in terms of essential drugs and supplies, equipment, and a referral system. Many household surveys report a reasonably high proportion of women delivering in health facilities. However, the quality and adequacy of facilities and personnel are often not assessed. The three delay model; 1) delay in making the decision to seek care; 2) delay in reaching an appropriate obstetric facility; and 3) delay in receiving appropriate care once at the facility guided this project. This paper examines aspects of the third delay by assessing quality of emergency obstetric care in terms of staffing, skills equipment and supplies. Methods We used data from a survey of 25 maternity health facilities within or near two slums in Nairobi that were mentioned by women in a household survey as places that they delivered. Ethical clearance was obtained from the Kenya Medical Research Institute. Permission was also sought from the Ministry of Health and the Medical Officer of Health. Data collection included interviews with the staff in-charge of maternity wards using structured questionnaires. We collected information on staffing levels, obstetric procedures performed, availability of equipment and supplies, referral system and health management information system. Results Out of the 25 health facilities, only two met the criteria for comprehensive emergency obstetric care (both located outside the two slums) while the others provided less than basic emergency obstetric care. Lack of obstetric skills, equipment, and supplies hamper many facilities from providing lifesaving emergency obstetric procedures. Accurate estimation of burden of morbidity and mortality was a challenge due to poor and incomplete medical records. Conclusion The quality of emergency obstetric care services in Nairobi slums is poor and needs improvement. Specific areas that require attention include supervision, regulation of maternity facilities; and ensuring that basic equipment, supplies, and trained personnel are available in order to handle obstetric complications in both public and private facilities. PMID:19284626

Assessment of infection control practices in maternity units in Southern Nigeria.

PubMed

Friday, Okonofua; Edoja, Okpokunu; Osasu, Aigbogun; Chinenye, Nwandu; Cyril, Mokwenye; Lovney, Kanguru; Julia, Hussein

2012-12-01

Puerperal sepsis accounts for 12% of maternal deaths in Nigeria. To date, little is known about the background hospital factors that predispose pregnant women to puerperal infection that leads to mortality. The objective of this study was to investigate the nature and pattern of existing policies and practices relating to infection control in maternity care centres in Edo state, South-South Nigeria. Cross-sectional study consisting of in-depth interviews with service providers, observation of clinical practices and examination of medical records. Public and private health-care facilities in eight local government areas (LGAs) selected from the three senatorial districts of Edo State, Nigeria. Health providers from 63 primary, secondary and tertiary maternity care centres. Sixty-three health-care facilities were sampled from eight LGAs from the three senatorial districts in Edo State. Three pre-tested tools were adapted to the local setting and used to interview key informants in the health facilities and to observe for practices and records relating to infection control. Of the 63 health facilities, 68% (43) reported that they had infection control procedures in place, while only 25% (16) reported that they documented these as manuals or charts. Only 13% (8) of facilities had infection control committees; 11% (7) routinely carried out audits of maternal deaths, while 33% (21) reported that they had an ongoing programme for staff training on infection control. A high proportion of the health facilities reported that staff routinely wash their hands before and after sterile procedures, but only half of the facilities were observed to have 24-h running water and only two-thirds had soap and antiseptic solutions in delivery and operating theatre areas. Although more than 90% (57) of the health facilities reported that they use sterile gloves routinely, unused sterile gloves were found in only 60% (38) of these facilities, and recycled gloves in 11.1% (7). The results of this study suggest the need for improved record-keeping procedures, the development of appropriate policies and protocols for infection control and staff training on infection control in maternity care facilities in Edo State. A public health education and advocacy programme to create awareness on clean delivery places as an approach for reducing maternal morbidity and mortality and to build political will for implementing related activities is also urgently needed.

Implementing at-scale, community-based distribution of misoprostol tablets to mothers in the third stage of labor for the prevention of postpartum haemorrhage in Sokoto State, Nigeria: Early results and lessons learned

PubMed Central

Orobaton, Nosakhare; Abdulazeez, Jumare; Abegunde, Dele; Shoretire, Kamil; Maishanu, Abubakar; Ikoro, Nnenna; Fapohunda, Bolaji; Balami, Wapada; Beal, Katherine; Ganiyu, Akeem; Gwamzhi, Ringpon; Austin, Anne

2017-01-01

Background Postpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale. Methods A community-based system for the distribution of misoprostol tablets (in 600ug) and chlorhexidine digluconate gel 7.1% to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013, with the potential to reach an estimated 190,467 annual births. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers’ conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths. Results Misoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014. Between April and December 2013, 33 women (< 1%) reported that heavy bleeding persisted after misoprostol use and were promptly referred. There were a total of 11 deaths in the 2013 cohort which were confirmed as maternal deaths by verbal autopsies. Between January and December of 2014, a total 434 women (1.25%) that ingested misoprostol reported associated side effects. Conclusion It is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State’s at-scale program implementation, to assure every mother’s right to uterotonics, can inform scale-up elsewhere in Nigeria. PMID:28234894

Signal functions for emergency obstetric care as an intervention for reducing maternal mortality: a survey of public and private health facilities in Lusaka District, Zambia.

PubMed

Tembo, Tannia; Chongwe, Gershom; Vwalika, Bellington; Sitali, Lungowe

2017-09-06

Zambia's maternal mortality ratio was estimated at 398/100,000 live births in 2014. Successful aversion of deaths is dependent on availability and usability of signal functions for emergency obstetric and neonatal care. Evidence of availability, usability and quality of signal functions in urban settings in Zambia is minimal as previous research has evaluated their distribution in rural settings. This survey evaluated the availability and usability of signal functions in private and public health facilities in Lusaka District of Zambia. A descriptive cross sectional study was conducted between November 2014 and February 2015 at 35 public and private health facilities. The Service Availability and Readiness Assessment tool was adapted and administered to overall in-charges, hospital administrators or maternity ward supervisors at health facilities providing maternal and newborn health services. The survey quantified infrastructure, human resources, equipment, essential drugs and supplies and used the UN process indicators to determine availability, accessibility and quality of signal functions. Data on deliveries and complications were collected from registers for periods between June 2013 and May 2014. Of the 35 (25.7% private and 74.2% public) health facilities assessed, only 22 (62.8%) were staffed 24 h a day, 7 days a week and had provided obstetric care 3 months prior to the survey. Pre-eclampsia/ eclampsia and obstructed labor accounted for most direct complications while postpartum hemorrhage was the leading cause of maternal deaths. Overall, 3 (8.6%) and 5 (14.3%) of the health facilities had provided Basic and Comprehensive EmONC services, respectively. All facilities obtained blood products from the only blood bank at a government referral hospital. The UN process indicators can be adequately used to monitor progress towards maternal mortality reduction. Lusaka district had an unmet need for BEmONC as health facilities fell below the minimum UN standard. Public health facilities with capacity to perform signal functions should be upgraded to Basic EmONC status. Efforts must focus on enhancing human resource capacity in EmONC and improving infrastructure and supply chain. Obstetric health needs and international trends must drive policy change.

Effects of the 2014 Ebola outbreak on antenatal care and delivery outcomes in Liberia: a nationwide analysis

PubMed Central

Horace-Kwemi, E.; Najjemba, R.; Owiti, P.; Edwards, J.; Shringarpure, K.; Bhat, P.; Kateh, F. N.

2017-01-01

Setting: All health facilities, public and private, in Liberia, West Africa. Objectives: To determine access to antenatal care (ANC), deliveries and their outcomes before, during and after the 2014–2015 Ebola outbreak. Design: This was a descriptive cross-sectional study. Result: During the Ebola outbreak in Liberia, overall monthly reporting from health facilities plunged by 43%. Access to ANC declined by 50% and reported deliveries fell by one third during the outbreak. Reported deliveries by skilled attendants and Caesarian section declined by respectively 32% and 60%. Facility-based deliveries dropped by 35% and reported community deliveries fell by 47%. There was an overall decline in reported stillbirths, maternal and neonatal deaths, by 50%, during the outbreak. ANC, reported deliveries and related outcomes returned to pre-outbreak levels within one year following the outbreak. Conclusion: The Liberian health system was considerably weakened during the Ebola outbreak and had difficulties providing basic maternal health services. In the light of the major reporting gaps during the Ebola period, and the reduced use of health facilities for maternal care, these findings highlight the need for measures to avoid such disruptions during future outbreaks. PMID:28744445

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

PubMed Central

Montagu, Dominic; Yamey, Gavin; Visconti, Adam; Harding, April; Yoong, Joanne

2011-01-01

Background In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. Methodology/Principal Findings We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. Conclusions In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer. PMID:21386886

Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.

PubMed

Montagu, Dominic; Yamey, Gavin; Visconti, Adam; Harding, April; Yoong, Joanne

2011-02-28

In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed "not necessary" by a household decision maker. Among the poorest women, "not necessary" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys.

PubMed

Kruk, Margaret E; Leslie, Hannah H; Verguet, Stéphane; Mbaruku, Godfrey M; Adanu, Richard M K; Langer, Ana

2016-11-01

Global efforts to increase births at health-care facilities might not reduce maternal or newborn mortality if quality of care is insufficient. However, little systematic evidence exists for the quality at health facilities caring for women and newborn babies in low-income countries. We analysed the quality of basic maternal care functions and its association with volume of deliveries and surgical capacity in health-care facilities in five sub-Saharan African countries. In this analysis, we combined nationally representative health system surveys (Service Provision Assessments by the Demographic and Health Survery Programme) with data for volume of deliveries and quality of delivery care from Kenya, Namibia, Rwanda, Tanzania, and Uganda. We measured the quality of basic maternal care functions in delivery facilities using an index of 12 indicators of structure and processes of care, including infrastructure and use of evidence-based routine and emergency care interventions. We regressed the quality index on volume of births and confounders (public or privately managed, availability of antiretroviral therapy services, availability of skilled staffing, and country) stratified by facility type: primary (no caesarean capacity) or secondary (has caesarean capacity) care facilities. The Harvard University Human Research Protection Program approved this analysis as exempt from human subjects review. The national surveys were completed between April, 2006, and May, 2010. Our sample consisted of 1715 (93%) of 1842 health-care facilities that provided normal delivery service, after exclusion of facilities with missing (n=126) or invalid (n=1) data. 1511 (88%) study facilities (site of 276 965 [44%] of 622 864 facility births) did not have caesarean section capacity (primary care facilities). Quality of basic maternal care functions was substantially lower in primary (index score 0·38) than secondary care facilities (0·77). Low delivery volume was consistently associated with poor quality, with differences in quality between the lowest versus highest volume facilities of -0·22 (95% CI -0·26 to -0·19) in primary care facilities and -0·17 (-0·21 to -0·11) in secondary care facilities. More than 40% of facility deliveries in these five African countries occurred in primary care facilities, which scored poorly on basic measures of maternal care quality. Facilities with caesarean section capacity, particularly those with birth volumes higher than 500 per year, had higher scores for maternal care quality. Low-income and middle-income countries should systematically assess and improve the quality of delivery care in health facilities to accelerate reduction of maternal and newborn deaths. None. Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. Published by Elsevier Ltd.. All rights reserved.

Implementing maternal death surveillance and response: a review of lessons from country case studies.

PubMed

Smith, Helen; Ameh, Charles; Roos, Natalie; Mathai, Matthews; Broek, Nynke van den

2017-07-17

Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation. A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful. MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a 'no shame, no blame' culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs. Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

Why some women fail to give birth at health facilities: A comparative study between Ethiopia and Nigeria.

PubMed

Yaya, Sanni; Bishwajit, Ghose; Uthman, Olalekan A; Amouzou, Agbessi

2018-01-01

Obstetric complications and maternal deaths can be prevented through safe delivery process. Facility based delivery significantly reduces maternal mortality by increasing women's access to skilled personnel attendance. However, in sub-Saharan Africa, most deliveries take place without skilled attendants and outside health facilities. Utilization of facility-based delivery is affected by socio-cultural norms and several other factors including cost, long distance, accessibility and availability of quality services. This study examined country-level variations of the self-reported causes of not choosing to deliver at a health facility. Cross-sectional data on 37,086 community dwelling women aged between 15-49 years were collected from DHS surveys in Ethiopia (n = 13,053) and Nigeria (n = 24,033). Outcome variables were the self-reported causes of not delivering at health facilities which were regressed against selected sociodemographic and community level determinants. In total eight items complaints were identified for non-use of facility delivery: 1) Cost too much 2) Facility not open, 3) Too far/no transport, 4) don't trust facility/poor service, 5) No female provider, 6) Husband/family didn't allow, 7) Not necessary, 8) Not customary. Multivariable regression methods were used for measuring the associations. In both countries a large proportion of the women mentioned facility delivery as not necessary, 54.9% (52.3-57.9) in Nigeria and 45.4% (42.0-47.5) in Ethiopia. Significant urban-rural variations were observed in the prevalence of the self-reported causes of non-utilisation. Women in the rural areas are more likely to report delivering at health facility as not customary/not necessary and healthy facility too far/no transport. However, urban women were more likely to complain that husband/family did not allow and that the costs were too high. Women in the rural were more likely to regard facility delivery as unnecessary and complain about transportation and financial difficulties. In order to achieving the maternal mortality related targets, addressing regional disparities in accessing maternal healthcare services should be regarded as a priority of health promotion programs in Nigeria and Ethiopia.

Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi.

PubMed

Colbourn, Tim; Pulkki-Brännström, Anni-Maria; Nambiar, Bejoy; Kim, Sungwook; Bondo, Austin; Banda, Lumbani; Makwenda, Charles; Batura, Neha; Haghparast-Bidgoli, Hassan; Hunter, Rachael; Costello, Anthony; Baio, Gianluca; Skordis-Worrall, Jolene

2015-01-01

Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale. Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $. The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi. Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby.

PubMed

Kerber, Kate J; Mathai, Matthews; Lewis, Gwyneth; Flenady, Vicki; Erwich, Jan Jaap H M; Segun, Tunde; Aliganyira, Patrick; Abdelmegeid, Ali; Allanson, Emma; Roos, Nathalie; Rhoda, Natasha; Lawn, Joy E; Pattinson, Robert

2015-01-01

While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings

PubMed Central

2014-01-01

Most of the maternal and newborn deaths occur at birth or within 24 hours of birth. Therefore, essential lifesaving interventions need to be delivered at basic or comprehensive emergency obstetric care facilities. Facilities provide complex interventions including advice on referrals, post discharge care, long-term management of chronic conditions along with staff training, managerial and administrative support to other facilities. This paper reviews the effectiveness of facility level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined facility level interventions and included 32 systematic reviews. Findings suggest that additional social support during pregnancy and labour significantly decreased the risk of antenatal hospital admission, intrapartum analgesia, dissatisfaction, labour duration, cesarean delivery and instrumental vaginal birth. However, it did not have any impact on pregnancy outcomes. Continued midwifery care from early pregnancy to postpartum period was associated with reduced medical procedures during labour and shorter length of stay. Facility based stress training and management interventions to maintain well performing and motivated workforce, significantly reduced job stress and improved job satisfaction while the interventions tailored to address identified barriers to change improved the desired practice. We found limited and inconclusive evidence for the impacts of physical environment, exit interviews and organizational culture modifications. At the facility level, specialized midwifery teams and social support during pregnancy and labour have demonstrated conclusive benefits in improving maternal newborn health outcomes. However, the generalizability of these findings is limited to high income countries. Future programs in resource limited settings should utilize these findings to implement relevant interventions tailored to their needs. PMID:25208539

Risk factors of pre-eclampsia/eclampsia and its adverse outcomes in low- and middle-income countries: a WHO secondary analysis.

PubMed

Bilano, Ver Luanni; Ota, Erika; Ganchimeg, Togoobaatar; Mori, Rintaro; Souza, João Paulo

2014-01-01

Pre-eclampsia has an immense adverse impact on maternal and perinatal health especially in low- and middle-income settings. We aimed to estimate the associations between pre-eclampsia/eclampsia and its risk factors, and adverse maternal and perinatal outcomes. We performed a secondary analysis of the WHO Global Survey on Maternal and Perinatal Health. The survey was a multi-country, facility-based cross-sectional study. A global sample consisting of 24 countries from three regions and 373 health facilities was obtained via a stratified multi-stage cluster sampling design. Maternal and offspring data were extracted from records using standardized questionnaires. Multi-level logistic regression modelling was conducted with random effects at the individual, facility and country levels. Data for 276,388 mothers and their infants was analysed. The prevalence of pre-eclampsia/eclampsia in the study population was 10,754 (4%). At the individual level, sociodemographic characteristics of maternal age ≥30 years and low educational attainment were significantly associated with higher risk of pre-eclampsia/eclampsia. As for clinical and obstetric variables, high body mass index (BMI), nulliparity (AOR: 2.04; 95%CI 1.92-2.16), absence of antenatal care (AOR: 1.41; 95%CI 1.26-1.57), chronic hypertension (AOR: 7.75; 95%CI 6.77-8.87), gestational diabetes (AOR: 2.00; 95%CI 1.63-2.45), cardiac or renal disease (AOR: 2.38; 95%CI 1.86-3.05), pyelonephritis or urinary tract infection (AOR: 1.13; 95%CI 1.03-1.24) and severe anemia (AOR: 2.98; 95%CI 2.47-3.61) were found to be significant risk factors, while having >8 visits of antenatal care was protective (AOR: 0.90; 95%CI 0.83-0.98). Pre-eclampsia/eclampsia was found to be a significant risk factor for maternal death, perinatal death, preterm birth and low birthweight. Chronic hypertension, obesity and severe anemia were the highest risk factors of preeclampsia/eclampsia. Implementation of effective interventions prioritizing risk factors, provision of quality health services during pre-pregnancy and during pregnancy for joint efforts in the areas of maternal health are recommended.

Socio-demographic characteristics and risk factors of ante-partum fetal death in a tertiary care hospital in Dhaka City.

PubMed

Azim, A K; Sultana, N; Chowdhury, S; Azim, E

2013-10-01

The objectives of this study were to assess the socio-demographic profile and to identify the risk factors of ante-partum fetal death which occurs after the age of viability of fetus. This prospective observational study was conducted in the Obstetrics and Gynaecology department of Ad-din Women Medical College Hospital from June 2009 to July 2010. A total of 14,015 pregnant patients were admitted in the study place after the age of viability, which was taken as 28 weeks of gestation for our facilities. Eighty-three (0.59%) of them were identified as intrauterine fetal death. Assessment of maternal socio-demographic characteristics and maternal-fetal risk factors were evaluated with a semi structured questionnaire which was pre-tested before executing in this study. Majority (81.92%, n=68) of the patients were below 30 years of age, 78.31% belonged to middle socioeconomic group. Almost 58% women had education below secondary school certificate (SSC) level and 28.91% took regular antenatal checkup. About 61.45% patients were multi-gravida. Most (59.04%) ante-partum deaths were identified below 32 weeks of pregnancy. Out of 83 patients, maternal risk factors were identified in 41(49.59%) cases where fetal risk factors were found in 16(19.27%) cases; no risk factors could be determined in rests. Hypertension (48.78%), diabetes (21.95%), hyperpyrexia (17.3%), abruptio placentae (4.88%) and UTI (7.36%) were identified as maternal factors; and congenital anomaly (37.5%), Rh incompatibility (37.5%), multiple pregnancy (12.5%) and post-maturity (12.5%) were the fetal risk factors. Here, proximal biological risk factors are most important in ante-partum fetal deaths. More investigations and facilities are needed to explain the causes of ante-partum deaths.

Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 2. maternal health findings

PubMed Central

Jennings, Mary Carol; Pradhan, Subarna; Schleiff, Meike; Sacks, Emma; Freeman, Paul A; Gupta, Sundeep; Rassekh, Bahie M; Perry, Henry B

2017-01-01

Background We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community–based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series. Methods We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation. Results 152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1–10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community–based interventions on antenatal care attendance, attended delivery and facility–based deliveries all showed a positive impact. The community–based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women’s groups, and provision of services by outreach teams from peripheral health facilities. Conclusions This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community– and facility–based approaches, emphasizing potential added benefits from such holistic approaches. Community–based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030. PMID:28685040

A comparison of sisterhood information on causes of maternal death with the registration causes of maternal death in Matlab, Bangladesh.

PubMed

Shahidullah, M

1995-10-01

To explore whether causes of maternal death can be investigated using the sisterhood method, an indirect method for providing a community-based estimate of the level of maternal mortality, this study compares the sisterhood causes of maternal death with the Matlab Demographic Surveillance System's (DSS) causes of maternal death. Data for this study came from the Matlab DSS, which has been in operation since 1966 as a field site of the International Centre for Diarrhoeal Disease Research, Bangladesh. The maternal deaths that occurred during the 15-year period from 1976 to 1990 in the Matlab DSS area are the basis of this study. A sisterhood survey was conducted in Matlab in November and December 1991 to collect information on conditions, events and symptoms that preceded death. The collected information was evaluated to assign a most likely cause of maternal death. The sisterhood survey cause of maternal death was then compared with the DSS cause of maternal death. Cause of death could not be assigned with reasonable confidence for 34 (11%) of the 305 maternal deaths for which information was collected. For the remaining deaths, the agreement between the two classification systems was generally high for most cause-of-death categories considered. Though cause-of-death information obtained by the sisterhood method will always be subject to some error, it can provide an indication of an overall distribution of causes of maternal deaths. This data can be used for the planning of programmes aimed at reducing maternal mortality and for the evaluation of such programmes over time.

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial.

PubMed

Colbourn, Tim; Nambiar, Bejoy; Bondo, Austin; Makwenda, Charles; Tsetekani, Eric; Makonda-Ridley, Agnes; Msukwa, Martin; Barker, Pierre; Kotagal, Uma; Williams, Cassie; Davies, Ros; Webb, Dale; Flatman, Dorothy; Lewycka, Sonia; Rosato, Mikey; Kachale, Fannie; Mwansambo, Charles; Costello, Anthony

2013-09-01

Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods. For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality. Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

Effects of quality improvement in health facilities and community mobilization through women’s groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial

PubMed Central

Colbourn, Tim; Nambiar, Bejoy; Bondo, Austin; Makwenda, Charles; Tsetekani, Eric; Makonda-Ridley, Agnes; Msukwa, Martin; Barker, Pierre; Kotagal, Uma; Williams, Cassie; Davies, Ros; Webb, Dale; Flatman, Dorothy; Lewycka, Sonia; Rosato, Mikey; Kachale, Fannie; Mwansambo, Charles; Costello, Anthony

2016-01-01

Background Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. Methods We evaluated a rural participatory women’s group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods. Results For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality. Conclusions Despite implementation problems, a combined community and facility approach using participatory women’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi. PMID:24030269

Spatial distribution of emergency obstetric and newborn care services in Ghana: Using the evidence to plan interventions.

PubMed

Bosomprah, Samuel; Tatem, Andrew J; Dotse-Gborgbortsi, Winfred; Aboagye, Patrick; Matthews, Zoe

2016-01-01

To provide clear policy directions for gaps in the provision of signal function services and sub-regions requiring priority attention using data from the 2010 Ghana Emergency Obstetric and Newborn Care (EmONC) survey. Using 2010 survey data, the fraction of facilities with only one or two signal functions missing was calculated for each facility type and EmONC designation. Thematic maps were used to provide insight into inequities in service provision. Of 1159 maternity facilities, 89 provided all the necessary basic or comprehensive EmONC signal functions 3months prior to the 2010 survey. Only 21% of facility-based births were in fully functioning EmONC facilities, but an additional 30% occurred in facilities missing one or two basic signal functions-most often assisted vaginal delivery and removal of retained products. Tackling these missing signal functions would extend births taking place in fully functioning facilities to over 50%. Subnational analyses based on estimated total pregnancies in each district revealed a pattern of inequity in service provision across the country. Upgrading facilities missing only one or two signal functions will allow Ghana to meet international standards for availability of EmONC services. Reducing maternal deaths will require high national priority given to addressing inequities in the distribution of EmONC services. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Newborn survival in Malawi: a decade of change and future implications.

PubMed

Zimba, Evelyn; Kinney, Mary V; Kachale, Fannie; Waltensperger, Karen Z; Blencowe, Hannah; Colbourn, Tim; George, Joby; Mwansambo, Charles; Joshua, Martias; Chanza, Harriet; Nyasulu, Dorothy; Mlava, Grace; Gamache, Nathalie; Kazembe, Abigail; Lawn, Joy E

2012-07-01

Malawi is one of two low-income sub-Saharan African countries on track to meet the Millennium Development Goal (MDG 4) for child survival despite high fertility and HIV and low health worker density. With neonatal deaths becoming an increasing proportion of under-five deaths, addressing newborn survival is critical for achieving MDG 4. We examine change for newborn survival in the decade 2000-10, analysing mortality and coverage indicators whilst considering other contextual factors. We assess national and donor funding, as well as policy and programme change for newborn survival using standard analyses and tools being applied as part of a multi-country analysis. Compared with the 1990s, progress towards MDG 4 and 5 accelerated considerably from 2000 to 2010. Malawi's neonatal mortality rate (NMR) reduced slower than annual reductions in mortality for children 1-59 months and maternal mortality (NMR reduced 3.5% annually). Yet, the NMR reduced at greater pace than the regional and global averages. A significant increase in facility births and other health system changes, including increased human resources, likely contributed to this decline. High level attention for maternal health and associated comprehensive policy change has provided a platform for a small group of technical and programme experts to link in high impact interventions for newborn survival. The initial entry point for newborn care in Malawi was mainly through facility initiatives, such as Kangaroo Mother Care. This transitioned to an integrated and comprehensive approach at community and facility level through the Community-Based Maternal and Newborn Care package, now being implemented in 17 of 28 districts. Addressing quality gaps, especially for care at birth in facilities, and including newborn interventions in child health programmes, will be critical to the future agenda of newborn survival in Malawi.

The quality of free antenatal and delivery services in Northern Sierra Leone.

PubMed

Koroma, Manso M; Kamara, Samuel S; Bangura, Evelyn A; Kamara, Mohamed A; Lokossou, Virgil; Keita, Namoudou

2017-07-12

The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone. A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities. The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care. The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

The effectiveness of community-based loan funds for transport during obstetric emergencies in developing countries: a systematic review.

PubMed

Nwolise, Chidiebere Hope; Hussein, Julia; Kanguru, Lovney; Bell, Jacqueline; Patel, Purvi

2015-09-01

Scarcity and costs of transport have been implicated as key barriers to accessing care when obstetric emergencies occur in community settings. Community-based loans have been used to increase utilization of health facilities and potentially reduce maternal mortality by providing funding at community level to provide emergency transport. This review aimed to provide evidence of the effect of community-based loan funds on utilization of health facilities and reduction of maternal mortality in developing countries. Electronic databases of published literature and websites were searched for relevant literature using a pre-defined set of search terms, inclusion and exclusion criteria. Screening of titles, abstracts and full-text articles were done by at least two reviewers independently. Quality assessment was carried out on the selected papers. Data related to deliveries and obstetric complications attended at facilities, maternal deaths and live births were extracted to measure and compare the effects of community-based loan funds using odds ratios (ORs) and reductions in maternal mortality ratio. Forest plots are presented where possible. The results of the review show that groups where community-based loan funds were implemented (alongside other interventions) generally recorded increases in utilization of health facilities for deliveries, with ORs of 3.5 (0.97-15.48) and 3.55 (1.56-8.05); and an increase in utilization of emergency obstetric care with ORs of 2.22 (0.51-10.38) and 3.37 (1.78-6.37). Intervention groups also experienced a positive effect on met need for complications and a reduction in maternal mortality. There is some evidence to suggest that community-based loan funds as part of a multifaceted intervention have positive effects. Conclusions are limited by challenges of study design and bias. Further studies which strengthen the evidence of the effects of loan funds, and mechanism for their functionality, are recommended. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.

Developing a framework to review near-miss maternal morbidity in India: a structured review and key stakeholder analysis.

PubMed

Bhattacharyya, Sanghita; Srivastava, Aradhana; Knight, Marian

2014-11-13

In India there is a thrust towards promoting institutional delivery, resulting in problems of overcrowding and compromise to quality of care. Review of near-miss obstetric events has been suggested to be useful to investigate health system functioning, complementing maternal death reviews. The aim of this project was to identify the key elements required for a near-miss review programme for India. A structured review was conducted to identify methods used in assessing near-miss cases. The findings of the structured review were used to develop a suggested framework for conducting near-miss reviews in India. A pool of experts in near-miss review methods in low and middle income countries (LMICs) was identified for vetting the framework developed. Opinions were sought about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that made implementation successful and the associated challenges. A draft of the framework was revised based on the experts' opinions. Five broad methods of near-miss case review/audit were identified: Facility-based near-miss case review, confidential enquiries, criterion-based clinical audit, structured case review (South African Model) and home-based interviews. The opinion of the 11 stakeholders highlighted that the methods that a facility adopts should depend on the type and number of cases the facility handles, availability and maintenance of a good documentation system, and local leadership and commitment of staff. A proposed framework for conducting near-miss reviews was developed that included a combination of criterion-based clinical audit and near-miss review methods. The approach allowed for development of a framework for researchers and planners seeking to improve quality of maternal care not only at the facility level but also beyond, encompassing community health workers and referral. Further work is needed to evaluate the implementation of this framework to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality.

Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection

PubMed Central

Halder, Amal K.; Streatfield, Peter K.; Sazzad, Hossain M.S.; Nurul Huda, Tarique M.; Hossain, M. Jahangir; Luby, Stephen P.

2012-01-01

Objectives. We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh. Methods. We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals. Results. We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV. Conclusions. Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed. PMID:23078501

Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study.

PubMed

Thonneau, Patrick F; Matsudai, Tomohiro; Alihonou, Eusèbe; De Souza, Jose; Faye, Ousseynou; Moreau, Jean-Charles; Djanhan, Yao; Welffens-Ekra, Christiane; Goyaux, Nathalie

2004-06-15

To assess the maternal mortality ratio in maternity units of reference hospitals in large west African cities, and to describe the distribution of complications and causes of maternal deaths. Prospective descriptive study in twelve reference maternities located in three African countries (Benin, Ivory Coast, Senegal). Data (clinical findings at hospital entry, medical history, complications, type of surgery, vital status of the women at discharge) were collected from obstetrical and surgical files and from admission hospital registers. All cases of maternal deaths were systematically reviewed by African and European staff. Of a total of 10,515 women, 1495 presented a major obstetric complication with dystocia or inappropriate management of the labour phase as the leading cause. Eighty-five maternal deaths were reported, giving a global hospital-based maternal mortality ratio of 800/100,000. Hypertensive disorders were involved in 25/85 cases (29%) and post-partum haemorrhage in 13/85 cases (15%). Relatively few cases (14) of major sepsis were reported, leading to three maternal deaths. The results of this multicentre study confirm the high rates of maternal mortality in maternity units of reference hospitals in large African cities, and in addition to dystocia the contribution of hypertensive disorders and post-partum haemorrhage to maternal deaths.

A 3-year retrospective review of mortality in women of reproductive age in a tertiary health facility in Port Harcourt, Nigeria.

PubMed

Orazulike, Ngozi C; Alegbeleye, Justina O; Obiorah, Christopher C; Nyengidiki, Tamunomie K; Uzoigwe, Samuel A

2017-01-01

To determine the causes of death and associated risk factors among women of reproductive age (WRA) in a tertiary institution in Port Harcourt, Nigeria. This was a retrospective survey of all deaths in women aged 15-49 years at the University of Port Harcourt Teaching Hospital that occurred from January 1, 2013 to December 31, 2015. Data retrieved from ward registers, death registers, and death certificates were analyzed with Epi Info version 7. Comparison of socioeconomic and demographic risk factors for maternal and nonmaternal deaths was done using a multivariate logistic regression model. There were 340 deaths in the WRA group over the 3-year period. The majority (155 [45.6%]) of the women were aged 30-39 years. There were 265 (77.9%) nonmaternal deaths and 75 (22.1%) maternal deaths. Among the nonmaternal deaths, 124 (46.8%) had infectious diseases, with human immunodeficiency virus being the most common cause of infection in this group. Breast cancer (13 [4.9%]), cervical cancer (12 [4.5%]), and ovarian cancer (11 [4.2%]) were the most common malignant neoplasms observed. Hypertensive disorders of pregnancy (31 [41.3%]) and puerperal sepsis (20 [26.7%]) were the most common causes of maternal deaths. Age and occupation were significantly associated with deaths in WRA ( p <0.05). Older women aged >30 years (odd ratio =1.86, 95% CI =1.07-3.23) and employed women (odds ratio =2.55, 95% CI =1.46-4.45) were more likely to die from nonmaternal than maternal causes. Most of the deaths were nonmaternal. Infectious diseases, diseases of the circulatory system, and malignant neoplasms were the major causes of death among WRA, with maternal deaths accounting for approximately a quarter. Public health programs educating women on safer sex practices, early screening for cancers, benefits of antenatal care, and skilled attendants at delivery will go a long way to reducing preventable causes of deaths among these women.

Maternal mortality in Bangladesh: a Countdown to 2015 country case study.

PubMed

El Arifeen, Shams; Hill, Kenneth; Ahsan, Karar Zunaid; Jamil, Kanta; Nahar, Quamrun; Streatfield, Peter Kim

2014-10-11

Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. The MMR fell from 322 deaths per 100,000 livebirths (95% CI 253-391) in 1998-2001 to 194 deaths per 100,000 livebirths (149-238) in 2007-10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh. United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness

PubMed Central

Dettinger, Julia; Calkins, Kimberly; Kibore, Minnie; Gachuno, Onesmus; Walker, Dilys

2018-01-01

Background Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model. Objective-method We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial. Findings Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%. Significance Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted. PMID:29474397

Maternal residential proximity to waste sites and industrial facilities and conotruncal heart defects in offspring.

PubMed

Langlois, Peter H; Brender, Jean D; Suarez, Lucina; Zhan, F Benjamin; Mistry, Jatin H; Scheuerle, Angela; Moody, Karen

2009-07-01

Most studies of the relationship between maternal residential proximity to sources of environmental pollution and congenital cardiovascular malformations have combined heart defects into one group or broad subgroups. The current case-control study examined whether risk of conotruncal heart defects, including subsets of specific defects, was associated with maternal residential proximity to hazardous waste sites and industrial facilities with recorded air emissions. Texas Birth Defects Registry cases were linked to their birth or fetal death certificate. Controls without birth defects were randomly selected from birth certificates. Distances from maternal addresses at delivery to National Priority List (NPL) waste sites, state superfund waste sites, and Toxic Release Inventory (TRI) facilities were determined for 1244 cases (89.5% of those eligible) and 4368 controls (88.0%). Living within 1 mile of a hazardous waste site was not associated with risk of conotruncal heart defects [adjusted odds ratio (aOR) = 0.83, 95% confidence interval (CI) = 0.54, 1.27]. This was true whether looking at most types of defects or waste sites. Only truncus arteriosus showed statistically elevated ORs with any waste site (crude OR: 2.80, 95% CI 1.19, 6.54) and with NPL sites (crude OR: 4.63, 95% CI 1.18, 13.15; aOR 4.99, 95% CI 1.26, 14.51), but the latter was based on only four exposed cases. There was minimal association between conotruncal heart defects and proximity to TRI facilities (aOR = 1.10, 95% CI = 0.91, 1.33). Stratification by maternal age or race/ethnic group made little difference in effect estimates for waste sites or industrial facilities. In this study population, maternal residential proximity to waste sites or industries with reported air emissions was not associated with conotruncal heart defects or its subtypes in offspring, with the exception of truncus arteriosus.

Hospitals by day, dispensaries by night: Hourly fluctuations of maternal mortality within Mexican health institutions, 2010-2014.

PubMed

Lamadrid-Figueroa, Hector; Montoya, Alejandra; Fritz, Jimena; Ortiz-Panozo, Eduardo; González-Hernández, Dolores; Suárez-López, Leticia; Lozano, Rafael

2018-01-01

Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths. To analyze the hourly variation of maternal mortality within Mexican health institutions. We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010-2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies. Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays. Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care.

Implementation of Fee-Free Maternal Health-Care Policy in Ghana: Perspectives of Users of Antenatal and Delivery Care Services From Public Health-Care Facilities in Accra.

PubMed

Anafi, Patricia; Mprah, Wisdom K; Jackson, Allen M; Jacobson, Janelle J; Torres, Christopher M; Crow, Brent M; O'Rourke, Kathleen M

2018-01-01

In 2008, the government of Ghana implemented a national user fee maternal care exemption policy through the National Health Insurance Scheme to improve financial access to maternal health services and reduce maternal as well as perinatal deaths. Although evidence shows that there has been some success with this initiative, there are still issues relating to cost of care to beneficiaries of the initiative. A qualitative study, comprising 12 focus group discussions and 6 interviews, was conducted with 90 women in six selected urban neighborhoods in Accra, Ghana, to examine users' perspectives regarding the implementation of this policy initiative. Findings showed that direct cost of delivery care services was entirely free, but costs related to antenatal care services and indirect costs related to delivery care still limit the use of hospital-based midwifery and obstetric care. There was also misunderstanding about the initiative due to misinformation created by the government through the media.We recommend that issues related to both direct and indirect costs of antenatal and delivery care provided in public health-care facilities must be addressed to eliminate some of the lingering barriers relating to cost hindering the smooth operation and sustainability of the maternal care fee exemption policy.

Essential childbirth and postnatal interventions for improved maternal and neonatal health

PubMed Central

2014-01-01

Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth. PMID:25177795

Reinforcing marginality? Maternal health interventions in rural Nicaragua.

PubMed

Kvernflaten, Birgit

2017-06-23

To achieve Millennium Development Goal 5 on maternal health, many countries have focused on marginalized women who lack access to care. Promoting facility-based deliveries to ensure skilled birth attendance and emergency obstetric care has become a main measure for preventing maternal deaths, so women who opt for home births are often considered 'marginal' and in need of targeted intervention. Drawing upon ethnographic data from Nicaragua, this paper critically examines the concept of marginality in the context of official efforts to increase institutional delivery amongst the rural poor, and discusses lack of access to health services among women living in peripheral areas as a process of marginalization. The promotion of facility birth as the new norm, in turn, generates a process of 're-marginalization', whereby public health officials morally disapprove of women who give birth at home, viewing them as non-compliers and a problem to the system. In rural Nicaragua, there is a discrepancy between the public health norm and women's own preferences and desires for home birth. These women live at the margins also in spatial and societal terms, and must relate to a health system they find incapable of providing good, appropriate care. Strong public pressure for institutional delivery makes them feel distressed and pressured. Paradoxically then, the aim of including marginal groups in maternal health programmes engenders resistance to facility birth.

Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis.

PubMed

Musafili, Aimable; Persson, Lars-Åke; Baribwira, Cyprien; Påfs, Jessica; Mulindwa, Patrick Adam; Essén, Birgitta

2017-03-11

Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival.

Newborn Survival Case Study in Rwanda - Bottleneck Analysis and Projections in Key Maternal and Child Mortality Rates Using Lives Saved Tool (LiST).

PubMed

Khurmi, Manpreet Singh; Sayinzoga, Felix; Berhe, Atakilt; Bucyana, Tatien; Mwali, Assumpta Kayinamura; Manzi, Emmanuel; Muthu, Maharajan

2017-01-01

The Newborn Survival Case study in Rwanda provides an analysis of the newborn health and survival situation in the country. It reviews evidence-based interventions and coverage levels already implemented in the country; identifies key issues and bottlenecks in service delivery and uptake of services by community/beneficiaries, and provides key recommendations aimed at faster reduction in newborn mortality rate. This study utilized mixed method research including qualitative and quantitative analyses of various maternal and newborn health programs implemented in the country. This included interviewing key stakeholders at each level, field visits and also interviewing beneficiaries for assessment of uptake of services. Monitoring systems such as Health Management Information Systems (HMIS), maternal and newborn death audits were reviewed and data analyzed to aid these analyses. Policies, protocols, various guidelines and tools for monitoring are already in place however, implementation of these remains a challenge e.g. infection control practices to reduce deaths due to sepsis. Although existing staff are quite knowledgeable and are highly motivated, however, shortage of health personnel especially doctors in an issue. New facilities are being operationalized e.g. at Gisenyi, however, the existing facilities needs expansion. It is essential to implement high impact evidence based interventions but coverage levels need to be significantly high in order to achieve higher reduction in newborn mortality rate. Equity approach should be considered in planning so that the services are better implemented and the poor and needy can get the benefits of public health programs.

Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study

PubMed Central

2014-01-01

Background The vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death. Methods This was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated. Results A total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD. Conclusions Although this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival. PMID:24886330

Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study.

PubMed

Pacagnella, Rodolfo C; Cecatti, José G; Parpinelli, Mary A; Sousa, Maria H; Haddad, Samira M; Costa, Maria L; Souza, João P; Pattinson, Robert C

2014-05-05

The vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death. This was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated. A total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD. Although this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

PubMed Central

2015-01-01

Background While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. Methods We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. Results Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. Conclusions Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges. PMID:26391558

Risk Factors of Pre-Eclampsia/Eclampsia and Its Adverse Outcomes in Low- and Middle-Income Countries: A WHO Secondary Analysis

PubMed Central

Bilano, Ver Luanni; Ota, Erika; Ganchimeg, Togoobaatar; Mori, Rintaro; Souza, João Paulo

2014-01-01

Background Pre-eclampsia has an immense adverse impact on maternal and perinatal health especially in low- and middle-income settings. We aimed to estimate the associations between pre-eclampsia/eclampsia and its risk factors, and adverse maternal and perinatal outcomes. Methods We performed a secondary analysis of the WHO Global Survey on Maternal and Perinatal Health. The survey was a multi-country, facility-based cross-sectional study. A global sample consisting of 24 countries from three regions and 373 health facilities was obtained via a stratified multi-stage cluster sampling design. Maternal and offspring data were extracted from records using standardized questionnaires. Multi-level logistic regression modelling was conducted with random effects at the individual, facility and country levels. Results Data for 276,388 mothers and their infants was analysed. The prevalence of pre-eclampsia/eclampsia in the study population was 10,754 (4%). At the individual level, sociodemographic characteristics of maternal age ≥30 years and low educational attainment were significantly associated with higher risk of pre-eclampsia/eclampsia. As for clinical and obstetric variables, high body mass index (BMI), nulliparity (AOR: 2.04; 95%CI 1.92–2.16), absence of antenatal care (AOR: 1.41; 95%CI 1.26–1.57), chronic hypertension (AOR: 7.75; 95%CI 6.77–8.87), gestational diabetes (AOR: 2.00; 95%CI 1.63–2.45), cardiac or renal disease (AOR: 2.38; 95%CI 1.86–3.05), pyelonephritis or urinary tract infection (AOR: 1.13; 95%CI 1.03–1.24) and severe anemia (AOR: 2.98; 95%CI 2.47–3.61) were found to be significant risk factors, while having >8 visits of antenatal care was protective (AOR: 0.90; 95%CI 0.83–0.98). Pre-eclampsia/eclampsia was found to be a significant risk factor for maternal death, perinatal death, preterm birth and low birthweight. Conclusion Chronic hypertension, obesity and severe anemia were the highest risk factors of preeclampsia/eclampsia. Implementation of effective interventions prioritizing risk factors, provision of quality health services during pre-pregnancy and during pregnancy for joint efforts in the areas of maternal health are recommended. PMID:24657964

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case–control study protocol in a tertiary healthcare facility in Lima, Peru

PubMed Central

Ayala Quintanilla, Beatriz Paulina; Pollock, Wendy E; McDonald, Susan J; Taft, Angela J

2018-01-01

Introduction Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU. Methods and analysis This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM. Ethics and dissemination Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals. PMID:29540421

Maternal deaths in the Nordic countries.

PubMed

Vangen, Siri; Bødker, Birgit; Ellingsen, Liv; Saltvedt, Sissel; Gissler, Mika; Geirsson, Reynir T; Nyfløt, Lill T

2017-09-01

Despite the seriousness of the event, maternal deaths are substantially underreported. There is often a missed opportunity to learn from such tragedies. The aim of the study was to identify maternal deaths in the five Nordic countries, to classify causes of death based on internationally acknowledged criteria, and to identify areas that would benefit from further teaching, training or research to possibly reduce the number of maternal deaths. We present data for the years 2005-2013. National audit groups collected data by linkage of registers and direct reporting from hospitals. Each case was then assessed to determine the cause of death, and level of care provided. Potential improvements to care were evaluated. We registered 168 maternal deaths, 90 direct and 78 indirect cases. The maternal mortality ratio was 7.2/100 000 live births ranging from 6.8 to 8.1 between the countries. Cardiac disease (n = 29) was the most frequent cause of death, followed by preeclampsia (n = 24), thromboembolism (n = 20) and suicide (n = 20). Improvements to care which could potentially have made a difference to the outcome were identified in one-third of the deaths, i.e. in as many as 60% of preeclamptic, 45% of thromboembolic, and 32% of the deaths from cardiac disease. Direct deaths exceeded indirect maternal deaths in the Nordic countries. To reduce maternal deaths, increased efforts to better implement existing clinical guidelines seem warranted, particularly for preeclampsia, thromboembolism and cardiac disease. More knowledge is also needed about what contributes to suicidal maternal deaths. © 2017 Nordic Federation of Societies of Obstetrics and Gynecology.

India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

PubMed

Lim, Stephen S; Dandona, Lalit; Hoisington, Joseph A; James, Spencer L; Hogan, Margaret C; Gakidou, Emmanuela

2010-06-05

In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes. We used data from the nationwide district-level household surveys done in 2002-04 and 2007-09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. Implementation of JSY in 2007-08 was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3.7 (95% CI 2.2-5.2) perinatal deaths per 1000 pregnancies and 2.3 (0.9-3.7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4.1 (2.5-5.7) perinatal deaths per 1000 pregnancies and 2.4 (0.7-4.1) neonatal deaths per 1000 livebirths. The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies. Bill & Melinda Gates Foundation. Copyright 2010 Elsevier Ltd. All rights reserved.

Health and socio-demographic profile of women of reproductive age in rural communities of southern Mozambique.

PubMed

Sacoor, Charfudin; Payne, Beth; Augusto, Orvalho; Vilanculo, Faustino; Nhacolo, Ariel; Vidler, Marianne; Makanga, Prestige Tatenda; Munguambe, Khátia; Lee, Tang; Macete, Eusébio; von Dadelszen, Peter; Sevene, Esperança

2018-01-01

Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12-49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20-24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20-24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities.

Maternal healthcare in context: A qualitative study of women's tactics to improve their experience of public healthcare in rural Burkina Faso.

PubMed

Østergaard, Lise Rosendal

2015-12-01

Improving the use of public maternal health facilities to prevent maternal death is a priority in developing countries. Accumulating evidence suggests that a key factor in choosing a facility-based delivery is the collaboration and the communication between healthcare providers and women. This article attempts to provide a fine-grained understanding of health system deficiencies, healthcare provider practices and women's experiences with maternal public healthcare. This article presents findings from ethnographic research conducted in the Central-East Region of Burkina Faso over a period of eight months (January-August 2013). It is based on monthly interviews with 14 women from village (10) and town (4) and on structured observations of clinical encounters in three primary healthcare facilities (two rural and one urban) (23 days). In addition, 13 health workers were interviewed and 11 focus groups with women from village (6) and town (5) were conducted (48 participants). Guided by an analytic focus on strategies and tactics and drawing on recent discussions on the notion of 'biomedical security', the article explores what tactics women employ in their efforts to maximize their chances of having a positive experience with public maternal healthcare. The synthesis of the cases shows that, in a context of poverty and social insecurity, women employ five tactics: establishing good relations with health workers, being mindful of their 'health booklet', attending prenatal care consultations, minimizing the waiting time at the maternity unit and using traditional medicines. In this way, women strive to achieve biomedical security for themselves and their child and to preserve their social reputation. The study reveals difficulty in the collaboration and communication between health workers and women and suggests that greater attention should be paid to social relations between healthcare providers and users. Copyright © 2015 Elsevier Ltd. All rights reserved.

Patterns of the Demographics, Clinical Characteristics, and Resource Utilization Among Maternal Decedents in Texas, 2001 - 2010: A Population-Based Cohort Study.

PubMed

Oud, Lavi

2015-12-01

Contemporary reporting of maternal mortality is focused on single, mutually exclusive causes of death among a minority of maternal decedents (pregnancy-related deaths), reflecting initial events leading to death. Although obstetric patients are susceptible to the lethal effects of downstream, more proximate contributors to death and to conditions not caused or precipitated by pregnancy, the burden of both categories and related patients' attributes is invisible to clinicians and healthcare policy makers with the current reporting system. Thus, the population-level demographics, clinical characteristics, and resource utilization associated with pregnancy-associated deaths in the United States have not been adequately characterized. We used the Texas Inpatient Public Use Data File to perform a population-based cohort study of the patterns of demographics, chronic comorbidity, occurrence of early maternal demise, potential contributors to maternal death, and resource utilization among maternal decedents in the state during 2001 - 2010. There were 557 maternal decedents during study period. Chronic comorbidity was reported in 45.2%. Most women (74.1%) were admitted to an ICU. Hemorrhage (27.8%), sepsis (23.5%), and cardiovascular conditions (22.6%) were the most commonly reported potential contributing conditions to maternal death, varying across categories of pregnancy-associated hospitalizations. More than one condition was reported in 39% of decedents. One in three women died during their first day of hospitalization, with no significant change over the past decade. The mean hospital length of stay was 7.9 days and total hospital charges were $250,000 or higher in 65 (11.7%) women. The findings of the high burden of chronic illness, patterns of occurrence of a broad array of potential contributing conditions to pregnancy-associated death, and the resource-intensive needs of a large contemporary population-based cohort of maternal decedents may better inform preventive and intervention measures at the bedside and as healthcare policy priorities. The prevalent and unchanged occurrence of rapid maternal demise following presentation for hospitalization supports a special focus on means to identify and effectively address front-line clinician- and healthcare system-related performance areas that can improve maternal outcomes. The common reporting of more than one potential contributing condition underscores the complexity of determination of causes of maternal death.

Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda.

PubMed

Doctor, Henry V; Nkhana-Salimu, Sangwani; Abdulsalam-Anibilowo, Maryam

2018-06-19

Sub-Saharan Africa remains one of the regions with modest health outcomes; and evidenced by high maternal mortality ratios and under-5 mortality rates. There are complications that occur during and following pregnancy and childbirth that can contribute to maternal deaths; most of which are preventable or treatable. Evidence shows that early and regular attendance of antenatal care and delivery in a health facility under the supervision of trained personnel is associated with improved maternal health outcomes. The aim of this study is to assess changes in and determinants of health facility delivery using nationally representative surveys in sub-Saharan Africa. This study also seeks to present renewed evidence on the determinants of health facility delivery within the context of the Agenda for Sustainable Development to generate evidence-based decision making and enable deployment of targeted interventions to improve health facility delivery and maternal and child health outcomes. We used pooled data from 58 Demographic and Health Surveys (DHS) conducted between 1990 and 2015 in 29 sub-Saharan African countries. This yielded a total of 1.1 million births occurring in the 5 years preceding the surveys. Descriptive statistics were used to describe the counts and proportions of women who delivered by place of delivery and their background characteristics at the time of delivery. We used multilevel logistic regression model to estimate the magnitude of association in the form of odds ratios between place of delivery and the predictors. Results show that births among women in the richest wealth quintile were 68% more likely to occur in health facilities than births among women in the lowest wealth quintile. Women with at least primary education were twice more likely to give birth in facilities than women with no formal education. Births from more recent surveys conducted since 2010 were 85% more likely to occur in facilities than births reported in earliest (1990s) surveys. Overall, the proportion of births occurring in facilities was 2% higher than would be expected; and varies by country and sub-Saharan African region. Proven interventions to increase health facility delivery should focus on addressing inequities associated with maternal education, women empowerment, increased access to health facilities as well as narrowing the gap between the rural and the urban areas. We further discuss these results within the agenda of leaving no one behind by 2030.

Assessment of utilization of long acting reversible contraceptive and associated factors among women of reproductive age in Harar City, Ethiopia.

PubMed

Shiferaw, Kasiye; Musa, Abdulbasit

2017-01-01

World health organization report indicated that, in 2013 alone, over 289,000 maternal death that resulted from pregnancy and delivery related complication were reported worldwide indicating a decline of 45% from 1990. The sub-Saharan Africa region alone accounted for 62% of maternal death followed by southern Asian country (24%). Provision of family planning is one of the effective intervention that prevent unwanted and ill spaced pregnancy there by reducing maternal mortality and morbidity. Given that its effectiveness and, associated fewer visits to health facilities, LARC are very important in tackling maternal mortality and morbidity. However, little is known regarding its prevalence in eastern Ethiopia. Thus, this study aimed to assess utilization of long acting reversible contraceptives and associated factors among women of reproductive age groups. A facility based cross-sectional study conducted in Harar city among 402 study participants. The study participants selected by using systematic random sampling method. The quantitative data collected using structured interviewer administered questionnaires. All variables with p-value of ≤ 0.25 in bivariate logistic regression were taken into multivariable model. Variables having p value ≤ 0.05 in the multivariate analysis were taken as significant predictors. Crude and adjusted odds ratios with their 95% confidence intervals were calculated. The study identified that the utilization of long acting reversible contraceptive among mother of reproductive age was 38%. Study participants whose occupation was daily laborer were less likely to utilize long acting reversible contraceptive compared to those whose occupation was house wife (adjusted OR = 0.3; 95% CI 0.01 to 0.8). Moreover, those mothers who were unable to read and write utilize long acting reversible contraceptive 5 times more likely compared to those who were above grade 12 (adjusted OR = 4.9; 95% CI 1.2 to 19.6). The prevalence of long acting reversible contraceptive was found to be low. Maternal education and occupation were factors found to have a significant association with utilization of long acting reversible contraceptive. Community and facility level awareness creation should be reinforced to improve utilization of long acting reversible contraceptives.

Maternal mortality ratio in Lebanon in 2008: a hospital-based reproductive age mortality study (RAMOS).

PubMed

Hobeika, Elie; Abi Chaker, Samer; Harb, Hilda; Rahbany Saad, Rita; Ammar, Walid; Adib, Salim

2014-01-01

International agencies have recently assigned Lebanon to the group H of countries with "no national data on maternal mortality," and estimated a corresponding maternal mortality ratio (MMR) of 150 per 100,000 live births. The Ministry of Public Health addressed the discrepancy perceived between the reality of the maternal mortality ratio experience in Lebanon and the international report by facilitating a hospital-based reproductive age mortality study, sponsored by the World Health Organization Representative Office in Lebanon, aiming at providing an accurate estimate of a maternal mortality ratio for 2008. The survey allowed a detailed analysis of maternal causes of deaths. Reproductive age deaths (15-49 years) were initially identified through hospital records. A trained MD traveled to each hospital to ascertain whether recorded deaths were in fact maternal deaths or not. ICD10 codes were provided by the medical controller for each confirmed maternal deaths. There were 384 RA death cases, of which 13 were confirmed maternal deaths (339%) (numerator). In 2008, there were 84823 live births in Lebanon (denominator). The MMR in Lebanon in 2008 was thus officially estimated at 23/100,000 live births, with an "uncertainty range" from 153 to 30.6. Hemorrhage was the leading cause of death, with double the frequency of all other causes (pregnancy-induced hypertension, eclampsia, infection, and embolism). This specific enquiry responded to a punctual need to correct a clearly inadequate report, and it should be relayed by an on-going valid surveillance system. Results indicate that special attention has to be devoted to the management of peri-partum hemorrhage cases. Arab, postpartum hemorrhage, development, pregnancy management, verbal autopsy

Women's social networks and use of facility delivery services for uncomplicated births in North West Ethiopia: a community-based case-control study.

PubMed

Asrese, Kerebih; Adamek, Margaret E

2017-12-28

High maternal mortality has remained an unmet public health challenge in the developing world. Maternal mortality in Ethiopia is among the highest in the world. Since most maternal deaths occur during labor, delivery, and the immediate postpartum period, facility delivery with skilled birth attendants is recommended to reduce maternal mortality. Nonetheless, the majority of women in Ethiopia give birth at home. Individual attributes and availability and accessibility of services deter service utilization. The role of social networks that may facilitate or constrain service use is not well studied. Community-based case-control study was conducted between February and March 2014 in Jabi Tehinan District, North West Ethiopia. Retrospective data were collected from 134 women who had uncomplicated births at health facilities and 140 women who had uncomplicated births at home within a year preceding the survey. Interviews were held with eight women who had uncomplicated births at health facilities and 11 who had uncomplicated births at home. The quantitative data were entered and analyzed using SPSS for Windows versions 16.0 and hierarchical logistic regression model was used for analysis. The qualitative data were transcribed verbatim and data were used to substantiate the quantitative data. The results indicated that social network variables were significantly associated with the use of health facilities for delivery. Taking social networks into account improved the explanation of facility use for delivery services over women's individual attributes. Women embedded within homogeneous network members (Adjusted OR 2.53; 95% CI: 1.26-5.06) and embedded within high SBA endorsement networks (Adjusted OR 7.97; 95% CI: 4.07-12.16) were more likely to deliver at health facilities than their counterparts. Women living in urban areas (Adjusted OR 3.32; 95% CI: 1.37-8.05) and had better knowledge of obstetric complications (Adjusted OR 3.01; 95% CI: 1.46-6.18) were more likely to deliver at health facilities. Social networks facilitate SBA utilization by serving as a reference for the behavior to deliver at health facilities. These findings inform health professionals and other stakeholders regarding the importance of considering women's social networks in designing intervention to increase the proportion of women who deliver at health facilities.

Improving quality for maternal care - a case study from Kerala, India

PubMed Central

Vlad, Ioana; Paily, VP; Sadanandan, Rajeev; Cluzeau, Françoise; Beena, M; Nair, Rajasekharan; Newbatt, Emma; Ghosh, Sujit; Sandeep, K; Chalkidou, Kalipso

2016-01-01

Background: The implementation of maternal health guidelines remains unsatisfactory, even for simple, well established interventions. In settings where most births occur in health facilities, as is the case in Kerala, India, preventing maternal mortality is linked to quality of care improvements. Context: Evidence-informed quality standards (QS), including quality statements and measurable structure and process indicators, are one innovative way of tackling the guideline implementation gap. Having adopted a zero tolerance policy to maternal deaths, the Government of Kerala worked in partnership with the Kerala Federation of Obstetricians & Gynaecologists (KFOG) and NICE International to select the clinical topic, develop and initiate implementation of the first clinical QS for reducing maternal mortality in the state. Description of practice: The NICE QS development framework was adapted to the Kerala context, with local ownership being a key principle. Locally generated evidence identified post-partum haemorrhage as the leading cause of maternal death, and as the key priority for the QS. A multidisciplinary group (including policy-makers, gynaecologists and obstetricians, nurses and administrators) was established. Multi-stakeholder workshops convened by the group ensured that the statements, derived from global and local guidelines, and their corresponding indicators were relevant and acceptable to clinicians and policy-makers in Kerala. Furthermore, it helped identify practical methods for implementing the standards and monitoring outcomes. Lessons learned: An independent evaluation of the project highlighted the equal importance of a strong evidence-base and an inclusive development process. There is no one-size-fits-all process for QS development; a principle-based approach might be a better guide for countries to adapt global evidence to their local context. PMID:27441084

Maternal mortality in Denmark, 1985-1994.

PubMed

Andersen, Betina Ristorp; Westergaard, Hanne Brix; Bødker, Birgit; Weber, Tom; Møller, Margrete; Sørensen, Jette Led

2009-02-01

In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985-1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD). All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group. 311 cases were classified. 92 deaths (29.6%) occurred 42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later). This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning. Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.

Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

PubMed

Vogel, J P; Souza, J P; Mori, R; Morisaki, N; Lumbiganon, P; Laopaiboon, M; Ortiz-Panozo, E; Hernandez, B; Pérez-Cuevas, R; Roy, M; Mittal, S; Cecatti, J G; Tunçalp, Ö; Gülmezoglu, A M

2014-03-01

We aimed to determine the prevalence and risks of late fetal deaths (LFDs) and early neonatal deaths (ENDs) in women with medical and obstetric complications. Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS). A total of 359 participating facilities in 29 countries. A total of 308 392 singleton deliveries. We reported on perinatal indicators and determined risks of perinatal death in the presence of severe maternal complications (haemorrhagic, infectious, and hypertensive disorders, and other medical conditions). Fresh and macerated LFDs (defined as stillbirths ≥ 1000 g and/or ≥28 weeks of gestation) and ENDs. The LFD rate was 17.7 per 1000 births; 64.8% were fresh stillbirths. The END rate was 8.4 per 1000 liveborns; 67.1% occurred by day 3 of life. Maternal complications were present in 22.9, 27.7, and 21.2% [corrected] of macerated LFDs, fresh LFDs, and ENDs, respectively. The risks of all three perinatal mortality outcomes were significantly increased with placental abruption, ruptured uterus, systemic infections/sepsis, pre-eclampsia, eclampsia, and severe anaemia. Preventing intrapartum-related perinatal deaths requires a comprehensive approach to quality intrapartum care, beyond the provision of caesarean section. Early identification and management of women with complications could improve maternal and perinatal outcomes. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

PubMed

Mahmood, Mohammad Afzal; Mufidah, Ismi; Scroggs, Steven; Siddiqui, Amna Rehana; Raheel, Hafsa; Wibdarminto, Koentijo; Dirgantoro, Bernardus; Vercruyssen, Jorien; Wahabi, Hayfaa A

2018-01-01

Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors

PubMed Central

Mufidah, Ismi; Scroggs, Steven; Siddiqui, Amna Rehana; Raheel, Hafsa; Wibdarminto, Koentijo; Dirgantoro, Bernardus; Vercruyssen, Jorien

2018-01-01

Background Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped. PMID:29682538

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience.

PubMed

Koch, Abigail R; Roesch, Pamela T; Garland, Caitlin E; Geller, Stacie E

2018-03-07

Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines. Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement. Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases). Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

Examining the impact of introducing ICD-MM on observed trends in maternal mortality rates in the UK 2003-13.

PubMed

Knight, Marian; Nair, Manisha; Brocklehurst, Peter; Kenyon, Sara; Neilson, James; Shakespeare, Judy; Tuffnell, Derek; Kurinczuk, Jennifer J

2016-07-20

The causes of maternal death are now classified internationally according to ICD-MM. One significant change with the introduction of ICD-MM in 2012 was the reclassification of maternal suicide from the indirect group to the direct group. This has led to concerns about the impact of this reclassification on calculated mortality rates. The aim of this analysis was to examine the trends in maternal deaths in the UK over the past 10 years, and to investigate the impact of reclassification using ICD-MM on the observed rates. Data about all maternal deaths between 2003-13 in the UK were included in this analysis. Data about maternal deaths occurring prior to 2009 were obtained from previously published reports. The deaths of women from 2009-13 during or after pregnancy were identified through the MBRRACE-UK Confidential Enquiry into Maternal Deaths. The underlying causes of maternal death were reclassified from a disease-based system to ICD-MM. Maternal mortality rates with 95 % confidence intervals were calculated using national data on the number of maternities as the denominator. Rate ratios with 95 % CI were calculated to compare the change in rates of maternal death as per ICD-MM relative to the old classification system. There was a decrease in the maternal death rate between 2003-05 and 2011-13 (rate ratio (RR) 0.65; 95 % CI 0.54-0.77 comparing 2003-5 with 2011-13; p = 0.005 for trend over time). The direct maternal death rate calculated using the old classification decreased with a RR of 0.47 (95 % CI 0.34-0.63) when comparing 2011-13 with 2003-05; p = 0.005 for trend over time. Reclassification using ICD-MM made little material difference to the observed trend in direct maternal death rates, RR = 0.51 (95 % CI 0.39-0.68) when comparing 2003-5 with 2011-13; p = 0.005 for trend over time. The impact of reclassifying maternal deaths according to ICD-MM in the UK was minimal. However, such reclassification raises awareness of maternal suicides and hence is the first step to actions to prevent women dying by suicide in the future. Recognising and acknowledging these women's deaths is more important than concerns over the impact reclassification using ICD-MM might have on reported maternal death rates.

Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study.

PubMed

Tsegay, Yalem; Gebrehiwot, Tesfay; Goicolea, Isabel; Edin, Kerstin; Lemma, Hailemariam; Sebastian, Miguel San

2013-05-14

Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15-49 years in Tigray, Ethiopia. The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation. The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband's occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands' occupation. A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.

Infrastructural challenges to better health in maternity facilities in rural Kenya: community and healthworker perceptions.

PubMed

Essendi, Hildah; Johnson, Fiifi Amoako; Madise, Nyovani; Matthews, Zoe; Falkingham, Jane; Bahaj, Abubakr S; James, Patrick; Blunden, Luke

2015-11-09

The efforts and commitments to accelerate progress towards the Millennium Development Goals for maternal and newborn health (MDGs 4 and 5) in low and middle income countries have focused primarily on providing key medical interventions at maternity facilities to save the lives of women at the time of childbirth, as well as their babies. However, in most rural communities in sub-Saharan, access to maternal and newborn care services is still limited and even where services are available they often lack the infrastructural prerequisites to function at the very basic level in providing essential routine health care services, let alone emergency care. Lists of essential interventions for normal and complicated childbirth, do not take into account these prerequisites, thus the needs of most health facilities in rural communities are ignored, although there is enough evidence that maternal and newborn deaths continue to remain unacceptably high in these areas. This study uses data gathered through qualitative interviews in Kitonyoni and Mwania sub-locations of Makueni County in Eastern Kenya to understand community and provider perceptions of the obstacles faced in providing and accessing maternal and newborn care at health facilities in their localities. The study finds that the community perceives various challenges, most of which are infrastructural, including lack of electricity, water and poor roads that adversely impact the provision and access to essential life-saving maternal and newborn care services in the two sub-locations. The findings and recommendations from this study are important for the attention of policy makers and programme managers in order to improve the state of lower-tier health facilities serving rural communities and to strengthen infrastructure with the aim of making basic routine and emergency obstetric and newborn care services more accessible.

Assessing health and economic outcomes of interventions to reduce pregnancy-related mortality in Nigeria.

PubMed

Erim, Daniel O; Resch, Stephen C; Goldie, Sue J

2012-09-14

Women in Nigeria face some of the highest maternal mortality risks in the world. We explore the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths. We adapt a previously validated maternal mortality model to Nigeria. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to Southwest and Northeast zones using survey-based data. Strategies consisted of improving coverage of effective interventions, and could include improved logistics. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality, was cost saving in the Southwest zone and cost-effective elsewhere, and prevented nearly 1 in 5 abortion-related deaths. However, with a singular focus on family planning and safe abortion, mortality reduction would plateau below MDG 5. Strategies that could prevent 4 out of 5 maternal deaths included an integrated and stepwise approach that includes increased skilled deliveries, facility births, access to antenatal/postpartum care, improved recognition of referral need, transport, and availability quality of EmOC in addition to family planning and safe abortion. The economic benefits of these strategies ranged from being cost-saving to having incremental cost-effectiveness ratios less than $500 per YLS, well below Nigeria's per capita GDP. Early intensive efforts to improve family planning and control of fertility choices, accompanied by a stepwise effort to scale-up capacity for integrated maternal health services over several years, will save lives and provide equal or greater value than many public health interventions we consider among the most cost-effective (e.g., childhood immunization).

Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda.

PubMed

Ngonzi, Joseph; Tornes, Yarine Fajardo; Mukasa, Peter Kivunike; Salongo, Wasswa; Kabakyenga, Jerome; Sezalio, Masembe; Wouters, Kristien; Jacqueym, Yves; Van Geertruyden, Jean-Pierre

2016-08-05

Maternal mortality is highest in sub-Saharan Africa. In Uganda, the WHO- MDG 5 (aimed at reducing maternal mortality by 75 % between 1990 and 2015) has not been attained. The current maternal mortality ratio (MMR) in Uganda is 438 per 100,000 live births coming from 550 per 100,000 in 1990. This study sets out to find causes and predictors of maternal deaths in a tertiary University teaching Hospital in Uganda. The study was a retrospective unmatched case control study which was carried out at the maternity unit of Mbarara Regional Referral Hospital (MRRH). The sample included pregnant women aged 15-49 years admitted to the Maternity unit between January 2011 and November 2014. Data from patient charts of 139 maternal deaths (cases) and 417 controls was collected using a standard audit/data extraction form. Multivariable logistic regression analysis was used to assess for the factors associated with maternal mortality. Direct causes of mortality accounted for 77.7 % while indirect causes contributed 22.3 %. The most frequent cause of maternal mortality was puerperal sepsis (30.9 %), followed by obstetric hemorrhage (21.6 %), hypertensive disorders in pregnancy (14.4 %), abortion complications (10.8 %). Malaria was the commonest indirect cause of mortality accounting for 8.92 %. On multivariable logistic regression analysis, the factors associated with maternal mortality were: primary or no education (OR 1.9; 95 % CI, 1.0-3.3); HIV positive sero-status (OR, 3.6; 95 % CI, 1.9-7.0); no antenatal care attendance (OR 3.6; 95 % CI, 1.8-7.0); rural dwellers (OR, 4.5; 95 % CI, 2.5-8.3); having been referred from another health facility (OR 5.0; 95 % CI, 2.9-10.0); delay to seek health care (delay-1) (OR 36.9; 95 % CI, 16.2-84.4). Most maternal deaths occur among mothers from rural areas, uneducated, HIV positive, unbooked mothers (lack of antenatal care), referred mothers in critical conditions and mothers delaying to seek health care. Puerperal sepsis is the leading cause of maternal deaths at Mbarara Regional Referral Hospital. Therefore more research into puerperal sepsis to describe the microbiology and epidemiology of sepsis is recommended.

PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana.

PubMed

Moyer, Cheryl A; Aborigo, Raymond A; Kaselitz, Elizabeth B; Gupta, Mira L; Oduro, Abraham; Williams, John

2016-03-09

While Ghana is a leader in some health indicators among West African nations, it still struggles with high maternal and neonatal morbidity and mortality rates, especially in the northern areas. The clinical causes of mortality and morbidity are relatively well understood in Ghana, but little is known about the impact of social and cultural factors on maternal and neonatal outcomes. Less still is understood about how such factors may vary by geographic location, and how such variability may inform locally-tailored solutions. Preventing Maternal And Neonatal Deaths (PREMAND) is a three-year, three-phase project that takes place in four districts in the Upper East, Upper West, and Northern Regions of Ghana. PREMAND will prospectively identify all maternal and neonatal deaths and 'near-misses', or those mothers and babies who survive a life threatening complication, in the project districts. Each event will be followed by either a social autopsy (in the case of deaths) or a sociocultural audit (in the case of near-misses). Geospatial technology will be used to visualize the variability in outcomes as well as the social, cultural, and clinical predictors of those outcomes. Data from PREMAND will be used to generate maps for local leaders, community members and Government of Ghana to identify priority areas for intervention. PREMAND is an effort of the Navrongo Health Research Centre and the University of Michigan Medical School. PREMAND uses an innovative, multifaceted approach to better understand and address neonatal and maternal morbidity and mortality in northern Ghana. It will provide unprecedented access to information on the social and cultural factors that contribute to deaths and near-misses in the project regions, and will allow such causal factors to be situated geographically. PREMAND will create the opportunity for local, regional, and national stakeholders to see how these events cluster, and place them relative to traditional healer compounds, health facilities, and other important geographic markers. Finally, PREMAND will enable local communities to generate their own solutions to maternal and neonatal morbidity and mortality, an effort that has great potential for long-term impact.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case-control study protocol in a tertiary healthcare facility in Lima, Peru.

PubMed

Ayala Quintanilla, Beatriz Paulina; Pollock, Wendy E; McDonald, Susan J; Taft, Angela J

2018-03-14

Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU. This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM. Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Identifying Factors Associated with Maternal Deaths in Jharkhand, India: A Verbal Autopsy Study

PubMed Central

Pradhan, Manas Ranjan

2013-01-01

Maternal mortality has been identified as a priority issue in health policy and research in India. The country, with an annual decrease of maternal mortality rate by 4.9% since 1990, now records 63,000 maternal deaths a year. India tops the list of countries with high maternal mortality. Based on a verbal autopsy study of 403 maternal deaths, conducted in 2008, this paper explores the missed opportunities to save maternal lives, besides probing into the socioeconomic factors contributing to maternal deaths in Jharkhand, India. This cross-sectional study was carried out in two phases, and a multistage sampling design was used in selecting deaths for verbal autopsy. Informed consent was taken into consideration before verbal autopsy. The analytical approach includes bivariate analysis using SPSS 15, besides triangulation of qualitative and quantitative findings. Most of the deceased were poor (89%), non-literates (85%), and housewives (74%). Again, 80% died in the community/at home, 28% died during pregnancy while another 26% died during delivery. Any antenatal care was received by merely 28% women, and only 20% of the deliveries were conducted by skilled birth attendants (doctors and midwives). Delays in decision-making, travel, and treatment compounded by ignorance of obstetric complications, inadequate use of maternal healthcare services, poor healthcare infrastructure, and harmful rituals are the major contributing factors of maternal deaths in India. PMID:23930345

Identifying factors associated with maternal deaths in Jharkhand, India: a verbal autopsy study.

PubMed

Khan, Nizamuddin; Pradhan, Manas Ranjan

2013-06-01

Maternal mortality has been identified as a priority issue in health policy and research in India. The country, with an annual decrease of maternal mortality rate by 4.9% since 1990, now records 63,000 maternal deaths a year. India tops the list of countries with high maternal mortality. Based on a verbal autopsy study of 403 maternal deaths, conducted in 2008, this paper explores the missed opportunities to save maternal lives, besides probing into the socioeconomic factors contributing to maternal deaths in Jharkhand, India. This cross-sectional study was carried out in two phases, and a multistage sampling design was used in selecting deaths for verbal autopsy. Informed consent was taken into consideration before verbal autopsy. The analytical approach includes bivariate analysis using SPSS 15, besides triangulation of qualitative and quantitative findings. Most of the deceased were poor (89%), non-literates (85%), and housewives (74%). Again, 80% died in the community/at home, 28% died during pregnancy while another 26% died during delivery. Any antenatal care was received by merely 28% women, and only 20% of the deliveries were conducted by skilled birth attendants (doctors and midwives). Delays in decision-making, travel, and treatment compounded by ignorance of obstetric complications, inadequate use of maternal healthcare services, poor healthcare infrastructure, and harmful rituals are the major contributing factors of maternal deaths in India.

Health and socio-demographic profile of women of reproductive age in rural communities of southern Mozambique

PubMed Central

Sacoor, Charfudin; Payne, Beth; Augusto, Orvalho; Vilanculo, Faustino; Nhacolo, Ariel; Vidler, Marianne; Makanga, Prestige Tatenda; Munguambe, Khátia; Lee, Tang; Macete, Eusébio; von Dadelszen, Peter; Sevene, Esperança

2018-01-01

Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12–49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20–24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20–24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities. PMID:29394247

Rural/Urban and Socioeconomic Differentials in Quality of Antenatal Care in Ghana

PubMed Central

Afulani, Patience A.

2015-01-01

Background Approximately 800 women die of pregnancy-related complications every day. Over half of these deaths occur in sub-Saharan Africa (SSA). Most maternal deaths can be prevented with high quality maternal health services. It is well established that use of maternal health services vary by place of residence and socioeconomic status (SES), but few studies have examined the determinants of quality of maternal health services in SSA. The purpose of this study is to examine the determinants of antenatal care (ANC) quality in Ghana–focusing on the role of place of residence and SES (education and wealth). The analysis also examines the interactions of these variables and the mediating role of ANC timing, frequency, facility type, and provider type. Methods The data are from the Ghana Maternal Health Survey (N = 4,868). Analytic techniques include multilevel linear regression with mediation and moderation analysis. Results Urban residence and higher SES are positively associated with higher ANC quality, but the urban effect is completely explained by sociodemographic factors. Specifically, about half of the urban effect is explained by education and wealth alone, with other variables accounting for the remainder. The effects of education are conditional on wealth and are strongest for poor women. Starting ANC visits early and attending the recommended four visits as well as receiving ANC from a higher level facility and from a skilled provider are associated with higher quality ANC. These factors partially explain the SES differentials. Implications Ghanaian women experience significant disparities in quality of ANC, with poor illiterate women receiving the worst care. Targeted efforts to increase quality of ANC may significantly reduce maternal health disparities in Ghana and SSA. A particularly crucial step is to improve ANC quality in the lower level health facilities, where the most vulnerable women are more likely to seek ANC. PMID:25695737

Impacts of maternal mortality on living children and families: A qualitative study from Butajira, Ethiopia.

PubMed

Molla, Mitike; Mitiku, Israel; Worku, Alemayehu; Yamin, Alicia

2015-05-06

The consequences of maternal mortality on orphaned children and the family members who support them are dramatic, especially in countries that have high maternal mortality like Ethiopia. As part of a four country, mixed-methods study (Ethiopia, Malawi, South Africa, and Tanzania) qualitative data were collected in Butajira, Ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children. We conducted interviews with 28 adult family members of women who died from maternal causes, as well as 13 stakeholders (government officials, civil society, and a UN agency); and held 10 focus group discussions with 87 community members. Data were analyzed using NVivo10 software for qualitative analysis. We found that newborns and children whose mothers died from maternal causes face nutrition deficits, and are less likely to access needed health care than children with living mothers. Older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age, and often choose migration in search of better opportunities. Family fragmentation is common following maternal death, leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources. Currently, there is no formal standardized support system for families caring for vulnerable children in Ethiopia. Impacts of maternal mortality on children are far-reaching and have the potential to last into adulthood. Coordinated, multi-sectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking. In order to prevent impacts on children and families, efforts targeting maternal mortality must address inequalities in access to care at the community, facility, and policy levels.

Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.

PubMed

Joharifard, Shahrzad; Rulisa, Stephen; Niyonkuru, Francine; Weinhold, Andrew; Sayinzoga, Felix; Wilkinson, Jeffrey; Ostermann, Jan; Thielman, Nathan M

2012-12-05

The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities. Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery. The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

Socio-clinical profile of married women with history of induced abortion: A community-based cross-sectional study in a rural area.

PubMed

Pattanaik, Sumitra; Patnaik, Lipilekha; Subhadarshini, Arpita; Sahu, Trilochan

2017-01-01

Induced abortion contributes significantly to maternal mortality in developing countries yet women still seek repeat induced abortion in spite of the availability of contraceptive services. (1) To study the sociodemographic profile of abortion seekers. (2) To study the reasons for procuring abortions by married women of reproductive age group. It was a cross-sectional community-based study. All the married women of reproductive age group (15-49 years) with a history of induced abortion were selected as the subjects. The most common reason for seeking an abortion was poverty (39.4%), followed by girl child and husband's insistence, which accounted for 17.2% each. More complications were noted in women undergoing an abortion in places other than government hospitals and also who did it in the second trimester. To reduce maternal deaths from unsafe abortion, several broad activities require strengthening such as decreasing unwanted pregnancies, increasing geographic accessibility and affordability, upgrading facilities that offers medical termination of pregnancy (MTP) services, increasing awareness among the reproductive age about the legal and safe abortion facilities, the consequences of unsafe abortion, ensuring appropriate referral facilities, increasing access to safe abortion services and increasing the quality of abortion care, including postabortion care.

Socio-clinical profile of married women with history of induced abortion: A community-based cross-sectional study in a rural area

PubMed Central

Pattanaik, Sumitra; Patnaik, Lipilekha; Subhadarshini, Arpita; Sahu, Trilochan

2017-01-01

Background: Induced abortion contributes significantly to maternal mortality in developing countries yet women still seek repeat induced abortion in spite of the availability of contraceptive services. Objectives: (1) To study the sociodemographic profile of abortion seekers. (2) To study the reasons for procuring abortions by married women of reproductive age group. Materials and Methods: It was a cross-sectional community-based study. All the married women of reproductive age group (15–49 years) with a history of induced abortion were selected as the subjects. Results: The most common reason for seeking an abortion was poverty (39.4%), followed by girl child and husband's insistence, which accounted for 17.2% each. More complications were noted in women undergoing an abortion in places other than government hospitals and also who did it in the second trimester. Conclusions: To reduce maternal deaths from unsafe abortion, several broad activities require strengthening such as decreasing unwanted pregnancies, increasing geographic accessibility and affordability, upgrading facilities that offers medical termination of pregnancy (MTP) services, increasing awareness among the reproductive age about the legal and safe abortion facilities, the consequences of unsafe abortion, ensuring appropriate referral facilities, increasing access to safe abortion services and increasing the quality of abortion care, including postabortion care. PMID:29026757

Experiences with and expectations of maternity waiting homes in Luapula Province, Zambia: a mixed-methods, cross-sectional study with women, community groups and stakeholders.

PubMed

Chibuye, Peggy S; Bazant, Eva S; Wallon, Michelle; Rao, Namratha; Fruhauf, Timothee

2018-01-25

Luapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women's and community's needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces. A cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata. Women who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women's decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain. Women and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women's needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable.

Reducing maternal deaths in a low resource setting in Nigeria.

PubMed

Ezugwu, E C; Agu, P U; Nwoke, M O; Ezugwu, F O

2014-01-01

To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria. A retrospective review of all maternal deaths between 1 st January, 2005 and 31 st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post-partum hemorrhage were adopted. These interventions strategy were carried out from 1 st January, 2008-31 st December, 2010 and the result compared with that before the interventions (2005-2007). Maternal mortality ratio (MMR) and case fatality rates. There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia. Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.

Towards an Inclusive and Evidence-Based Definition of the Maternal Mortality Ratio: An Analysis of the Distribution of Time after Delivery of Maternal Deaths in Mexico, 2010-2013

PubMed Central

Fritz, Jimena; Olvera, Marisela; Torres, Luis M.; Lozano, Rafael

2016-01-01

Progress towards the Millennium Development Goal No. 5 was measured by an indicator that excluded women who died due to pregnancy and childbirth after 42 days from the date of delivery. These women suffered from what are defined as late deaths and sequelae-related deaths (O96 and O97 respectively, according to the International Classification of Diseases, 10th revision). Such deaths end up not being part of the numerator in the calculation of the Maternal Mortality Ratio (MMR), the indicator that governments and international agencies use for reporting. The issue is not trivial since these deaths account for a sizeable fraction of all maternal deaths in the world and show an upward trend over time in many countries. The aim of this study was to analyze empirical data on maternal deaths that occurred between 2010 and 2013 in Mexico, linking databases of the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) and the Birth Information Subsystem (SINAC) of the Ministry of Health. Data were analyzed by negative binomial regression, survival analysis and multiple cause analysis. While the reported MMR decreased by 5% per year between 2010 and 2013, the MMR due to late and sequelae-related deaths doubled from 3.5 to 7 per 100,000 live-births in 2013 (p <0.01). A survival analysis of all maternal deaths revealed nothing particular around the 42 day threshold, other than the exclusion of 18% of women who died due to childbirth in 2013. The multiple cause analysis showed a strong association between the excluded deaths and obstetric causes. It is suggested to review the construction of the MMR to make it a more inclusive and dignified measurement of maternal mortality by including all deaths due to pregnancy and childbirth into the Maternal Death definition. PMID:27310260

The relationship between maternal education and mortality among women giving birth in health care institutions: analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health.

PubMed

Karlsen, Saffron; Say, Lale; Souza, João-Paulo; Hogue, Carol J; Calles, Dinorah L; Gülmezoglu, A Metin; Raine, Rosalind

2011-07-29

Approximately one-third of a million women die each year from pregnancy-related conditions. Three-quarters of these deaths are considered avoidable. Millennium Development Goal five calls for a reduction in maternal mortality and the establishment of universal access to high quality reproductive health care. There is evidence of a relationship between lower levels of maternal education and higher maternal mortality. This study examines the relationship between maternal education and maternal mortality among women giving birth in health care institutions and investigates the association of maternal age, marital status, parity, institutional capacity and state-level investment in health care with these relationships. Cross-sectional information was collected on 287,035 inpatients giving birth in 373 health care institutions in 24 countries in Africa, Asia and Latin America, between 2004-2005 (in Africa and Latin America) and 2007-2008 (in Asia) as part of the WHO Global Survey on Maternal and Perinatal Health. Analyses investigated associations between indicators measured at the individual, institutional and country level and maternal mortality during the intrapartum period: from admission to, until discharge from, the institution where women gave birth. There were 363 maternal deaths. In the adjusted models, women with no education had 2.7 times and those with between one and six years of education had twice the risk of maternal mortality of women with more than 12 years of education. Institutional capacity was not associated with maternal mortality in the adjusted model. Those not married or cohabiting had almost twice the risk of death of those who were. There was a significantly higher risk of death among those aged over 35 (compared with those aged between 20 and 25 years), those with higher numbers of previous births and lower levels of state investment in health care. There were also additional effects relating to country of residence which were not explained in the model. Lower levels of maternal education were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum care. More attention should be given to the wider social determinants of health when devising strategies to reduce maternal mortality and to achieve the increasingly elusive MDG for maternal mortality.

Critical maternal health knowledge gaps in low- and middle-income countries for the post-2015 era.

PubMed

Kendall, Tamil; Langer, Ana

2015-06-05

Effective interventions to promote maternal health and address obstetric complications exist, however 800 women die every day during pregnancy and childbirth from largely preventable causes and more than 90% of these deaths occur in low and middle income countries (LMIC). In 2014, the Maternal Health Task Force consulted 26 global maternal health researchers to identify persistent and critical knowledge gaps to be filled to reduce maternal morbidity and mortality and improve maternal health. The vision of maternal health articulated was comprehensive and priorities for knowledge generation encompassed improving the availability, accessibility, acceptability, and quality of institutional labor and delivery services and other effective interventions, such as contraception and safe abortion services. Respondents emphasized the need for health systems research to identify models that can deliver what is known to be effective to prevent and treat the main causes of maternal death at scale in different contexts and to sustain coverage and quality over time. Researchers also emphasized the development of tools to measure quality of care and promote ongoing quality improvement at the facility, district, and national level. Knowledge generation to improve distribution and retention of healthcare workers, facilitate task shifting, develop and evaluate training models to improve "hands-on" skills and promote evidence-based practice, and increase managerial capacity at different levels of the health system were also prioritized. Interviewees noted that attitudes, behavior, and power relationships between health professionals and within institutions must be transformed to achieve coverage of high-quality maternal health services in LMIC. The increasing burden of non-communicable diseases, urbanization, and the persistence of social and economic inequality were identified as emerging challenges that require knowledge generation to improve health system responses and evaluate progress. Respondents emphasized evaluating effectiveness, feasibility, and equity impacts of health system interventions. A prominent role for implementation science, evidence for policy advocacy, and interdisciplinary collaboration were identified as critical areas for knowledge generation to improve maternal health in the post-2015 era.

The cultural environment behind successful maternal death and morbidity reviews.

PubMed

Lewis, G

2014-09-01

This paper discusses some of the background principles which, through wide experience of instituting reviews of maternal deaths or near-misses around the world, appear common to their successful introduction. A supportive culture at personal, institutional and national level underpinned by the fostering of professionalism and the development of an ethos of safety against a wider supportive environment is needed. Reviews undertaken at a local level are as beneficial as those at a regional or population level and should be encouraged as a routine part of the quality improvement agenda for each and every healthcare facility. © 2014 The Authors BJOG An International Journal of Obsetrics and Gynaecology © 2014 RCOG.

Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story.

PubMed

Anastasi, Erin; Ekanem, Ekanem; Hill, Olivia; Adebayo Oluwakemi, Agnes; Abayomi, Oluwatosin; Bernasconi, Andrea

2017-01-01

Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos. The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected. Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894-1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility. The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from poor, marginalized, and hard-to-reach populations in order to identify pockets of marginalization needing additional resources and tailored approaches to guarantee equitable treatment and timely access to quality health services for vulnerable groups. This study demonstrates the importance of sub-regional, disaggregated data to identify and redress inequities that exist among poor, remote, vulnerable populations-as in the urban slums of Lagos.

Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story

PubMed Central

Adebayo Oluwakemi, Agnes; Abayomi, Oluwatosin

2017-01-01

Introduction Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos. Materials and methods The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected. Results Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894–1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility. Discussion The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from poor, marginalized, and hard-to-reach populations in order to identify pockets of marginalization needing additional resources and tailored approaches to guarantee equitable treatment and timely access to quality health services for vulnerable groups. This study demonstrates the importance of sub-regional, disaggregated data to identify and redress inequities that exist among poor, remote, vulnerable populations—as in the urban slums of Lagos. PMID:28489890

Survival of neonates in rural Southern Tanzania: does place of delivery or continuum of care matter?

PubMed

Nathan, Rose; Mwanyangala, Mathew Alexander

2012-03-23

The concept of continuum of care has recently been highlighted as a core principle of maternal, newborn and child health initiatives, and as a means to save lives. However, evidence has consistently revealed that access to care during and post delivery (intra and postpartum) remains a challenge in the continuum of care framework. In places where skilled delivery assistance is exclusively available in health facilities, access to health facilities is critical to the survival of the mother and her newborn. However, little is known about the association of place of delivery and survival of neonates. This paper uses longitudinal data generated in a Health and Demographic Surveillance System in rural Southern Tanzania to assess associations of neonatal mortality and place of delivery. Three cohorts of singleton births (born 2005, 2006 and 2007) were each followed up from birth to 28 days. Place of birth was classified as either "health facility" or "community". Neonatal mortality rates were produced for each year and by place of birth. Poisson regression was used to estimate crude relative risks of neonatal death by place of birth. Adjusted ratios were derived by controlling for maternal age, birth order, maternal schooling, sex of the child and wealth status of the maternal household. Neonatal mortality for health facility singleton deliveries in 2005 was 32.3 per 1000 live births while for those born in the community it was 29.7 per 1000 live births. In 2006, neonatal mortality rates were 28.9 and 26.9 per 1,000 live births for deliveries in health facilities and in the community respectively. In 2007 neonatal mortality rates were 33.2 and 27.0 per 1,000 live births for those born in health facilities and in the community respectively. Neonates born in a health facility had similar chances of dying as those born in the community in all the three years of study. Adjusted relative risks (ARR) for neonatal death born in a health facility in 2005, 2006 and 2007 were 0.99 (95% CI: 0.58 - 1.70), 0.98 (95% CI: 0.62 - 1.54) and 1.18 (95% CI: 0.76 - 1.85) respectively. We found no evidence to suggest that delivery in health facilities was associated with better survival chances of the neonates.

Risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis.

PubMed

Daru, Jahnavi; Zamora, Javier; Fernández-Félix, Borja M; Vogel, Joshua; Oladapo, Olufemi T; Morisaki, Naho; Tunçalp, Özge; Torloni, Maria Regina; Mittal, Suneeta; Jayaratne, Kapila; Lumbiganon, Pisake; Togoobaatar, Ganchimeg; Thangaratinam, Shakila; Khan, Khalid S

2018-05-01

Anaemia affects as many as half of all pregnant women in low-income and middle-income countries, but the burden of disease and associated maternal mortality are not robustly quantified. We aimed to assess the association between severe anaemia and maternal death with data from the WHO Multicountry Survey on maternal and newborn health. We used multilevel and propensity score regression analyses to establish the relation between severe anaemia and maternal death in 359 health facilities in 29 countries across Latin America, Africa, the Western Pacific, eastern Mediterranean, and southeast Asia. Severe anaemia was defined as antenatal or postnatal haemoglobin concentrations of less than 70 g/L in a blood sample obtained before death. Maternal death was defined as death any time after admission until the seventh day post partum or discharge. In regression analyses, we adjusted for post-partum haemorrhage, general anaesthesia, admission to intensive care, sepsis, pre-eclampsia or eclampsia, thrombocytopenia, shock, massive transfusion, severe oliguria, failure to form clots, and severe acidosis as confounding variables. These variables were used to develop the propensity score. 312 281 women admitted in labour or with ectopic pregnancies were included in the adjusted multilevel logistic analysis, and 12 470 were included in the propensity score regression analysis. The adjusted odds ratio for maternal death in women with severe anaemia compared with those without severe anaemia was 2·36 (95% CI 1·60-3·48). In the propensity score analysis, severe anaemia was also associated with maternal death (adjusted odds ratio 1·86 [95% CI 1·39-2·49]). Prevention and treatment of anaemia during pregnancy and post partum should remain a global public health and research priority. Barts and the London Charity. Copyright This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

Risk of fetal death associated with maternal drug dependence and placental abruption: a population-based study.

PubMed

McDonald, Sarah D; Vermeulen, Marian J; Ray, Joel G

2007-07-01

Substance use in pregnancy is associated with placental abruption, but the risk of fetal death independent of abruption remains undetermined. Our objective was to examine the effect of maternal drug dependence on placental abruption and on fetal death in association with abruption and independent of it. To examine placental abruption and fetal death, we performed a retrospective population-based study of 1 854 463 consecutive deliveries of liveborn and stillborn infants occurring between January 1, 1995 and March 31, 2001, using the Canadian Institute for Health Information Discharge Abstract Database. Maternal drug dependence was associated with a tripling of the risk of placental abruption in singleton pregnancies (adjusted odds ratio [OR] 3.1; 95% confidence intervals [CI] 2.6-3.7), but not in multiple gestations (adjusted OR 0.88; 95% CI 0.12-6.4). Maternal drug dependence was associated with an increased risk of fetal death independent of abruption (adjusted OR 1.6: 95% CI 1.1-2.2) in singleton pregnancies, but not in multiples. Risk of fetal death was increased with placental abruption in both singleton and multiple gestations, even after controlling for drug dependence (adjusted OR 11.4 in singleton pregnancy; 95% CI 10.6-12.2, and 3.4 in multiple pregnancy; 95% CI 2.4-4.9). Maternal drug use is associated with an increased risk of intrauterine fetal death independent of placental abruption. In singleton pregnancies, maternal drug dependence is associated with an increased risk of placental abruption.

Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project.

PubMed

Ellard, David R; Shemdoe, Aloisia; Mazuguni, Festo; Mbaruku, Godfrey; Davies, David; Kihaile, Paul; Pemba, Senga; Bergström, Staffan; Nyamtema, Angelo; Mohamed, Hamed-Mahfoudh; O'Hare, Joseph Paul

2016-02-12

During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A taxonomy and results from a comprehensive review of 28 maternal health voucher programmes.

PubMed

Bellows, Ben W; Conlon, Claudia M; Higgs, Elizabeth S; Townsend, John W; Nahed, Matta G; Cavanaugh, Karen; Grainger, Corinne G; Okal, Jerry; Gorter, Anna C

2013-12-01

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.

A Taxonomy and Results from a Comprehensive Review of 28 Maternal Health Voucher Programmes

PubMed Central

Conlon, Claudia M.; Higgs, Elizabeth S.; Townsend, John W.; Nahed, Matta G.; Cavanaugh, Karen; Grainger, Corinne G.; Okal, Jerry; Gorter, Anna C.

2013-01-01

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.

Maternal mortality in Vietnam in 1994-95.

PubMed

Hieu, D T; Hanenberg, R; Vach, T H; Vinh, D Q; Sokal, D

1999-12-01

This report presents the first population-based estimates of maternal mortality in Vietnam. All the deaths of women aged 15-49 in 1994-95 in three provinces of Vietnam were identified and classified by cause. Maternal mortality was the fifth most frequent cause of death. The maternal mortality ratio was 155 deaths per 100,000 live births. This ratio compares with the World Health Organization's estimates of 430 such deaths globally and 390 for Asia. The maternal mortality ratio in the delta regions of these provinces was half that of the mountainous and semimountainous regions. Because a larger proportion of the Vietnamese population live in delta regions than elsewhere, the maternal mortality ratio for Vietnam as a whole may be lower than that of the three provinces studied. Maternal mortality is low in Vietnam primarily because a relatively high proportion of deliveries take place in clinics and hospitals, where few women die in childbirth. Also, few women die of the consequences of induced abortion in Vietnam because the procedure is legal and easily available.

Maternal deaths in Denmark 2002-2006.

PubMed

Bødker, Birgit; Hvidman, Lone; Weber, Tom; Møller, Margrethe; Aarre, Annette; Nielsen, Karen Marie; Sørensen, Jette Led

2009-01-01

To describe a method for identification, classification and assessment of maternal deaths in Denmark and to identify substandard care. Register study and case audit based on data from the Registers of the Danish Medical Health Board, death certificates and hospital records. Denmark 2002-2006. Women who died during a pregnancy or within 42 days after a pregnancy. Maternal deaths were identified by notification from maternity wards and data from the Danish National Board of Health. A national audit committee assessed hospital records of direct and indirect deaths. Maternal mortality ratio, causes of death and suboptimal care. In the study period, 26 women died during pregnancy or within 42 days from direct or indirect causes, leading to a maternal mortality ratio of 8.0/100,000 live births. Causes of death were cardiac disease, thromboembolism, hypertensive disorders of pregnancy, Streptococcus A infections, suicide, amniotic fluid embolism, cerebrovascular hemorrhage, asthma and diabetes. Our method proved valid and can be used for future research. Causes of death could be identified and learning points from the assessments could form the basis of focused education and guidelines. Future complementary 'near miss' studies and cooperation with other countries with comparable health systems are expected to improve the benefits of the enquiries, contributing to improved management of life-threatening conditions in pregnancy and childbirth.

Millennium Development Goals 4 and 5: progress and challenges.

PubMed

Bryce, Jennifer; Black, Robert E; Victora, Cesar G

2013-10-16

The Millennium Development Goals have galvanized efforts to improve child survival (MDG-4) and maternal health (MDG-5). There has been important progress on both MDGs at global level, although it now appears that few countries will reach them by the target date of 2015. There are known and efficacious interventions to address most of the major causes of these deaths, but important gaps remain. The biggest challenge is to ensure that all women and children have access to life-saving interventions. Current levels of intervention coverage are too low, representing missed opportunities. Providing services at the community level is an important emerging priority, but preventing maternal and neonatal deaths also requires access to health facilities. Readers of the Medicine for Global Health collection in BMC Medicine are urged to make maternal and child health one of their key concerns, even if they work on other topics.

Increasing women's access to skilled pregnancy care to reduce maternal and perinatal mortality in rural Edo State, Nigeria: a randomized controlled trial.

PubMed

Yaya, Sanni; Okonofua, Friday; Ntoimo, Lorretta; Kadio, Bernard; Deuboue, Rodrigue; Imongan, Wilson; Balami, Wapada

2018-01-01

Nigeria presently has the second highest absolute number of maternal deaths and perinatal deaths (stillbirth and neonatal deaths) in the world. The country accounts for up to 14% of global maternal deaths and is second only to India in the number of women who die during childbirth. Although all parts of the country are worsened by these staggering statistics, several lines of evidence show that most maternal, and perinatal deaths occur in the north-east and north-west geo-political zones where women have limited access to evidence-based maternal and neonatal health services. The proposed project intends to identify the demand and supply factors that prevent women from using PHCs for maternal and early new-born care in Nigeria, and to test innovative and community relevant interventions for improving women's access to PHC services, and thus, ultimately, to prevent maternal and perinatal deaths. An open-labelled, randomized controlled trial will is carried out in two local government areas selected based on three criteria (i) maternal mortality rates (ii) PHC utilization rates and (iii) and geographic localization. The study will be conducted over 54-months in six communities, with PHCs in six communities of similar status serving as control sites. Surveys about quality of care and maternal health services utilization will be carried out at baseline, at midterm and at end of the project to test the effectiveness of the intervention, alongside conventional epidemiological measures of maternal and perinatal mortality. Ethical approval for the study has been granted (reference no. NHREC/01/01/2007). The findings will be published in compliance with reporting guidelines for randomized controlled trials. The current Federal Government in Nigeria has identified PHC as its main strategy for increasing access to health in Nigeria. However, despite numerous efforts, there are persisting concerns that there is currently no scientific evidence on which to base the improvement of PHCs. The results of this study will identify barriers in the use of PHCs and will provide scientific evidence for effective and innovative interventions for improving PHCs that can be rolled out throughout the country. Clinical Trials.gov NCT02643953.

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience.

PubMed

Haver, Jaime; Ansari, Nasratullah; Zainullah, Partamin; Kim, Young-Mi; Tappis, Hannah

2016-01-01

Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two-thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self-administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before-and-after study was to determine the effectiveness of advance distribution of misoprostol for self-administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. Cross-sectional household surveys were conducted pre- (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large-scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self-reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self-administration. © 2016 The Authors. The Journal of Midwifery and Women's Health, published by Wiley Periodicals, Inc., on behalf of the American College of Nurse-Midwives.

The Effect of the Removal of User Fees for Delivery at Public Health Facilities on Institutional Delivery in Urban Kenya.

PubMed

Calhoun, Lisa M; Speizer, Ilene S; Guilkey, David; Bukusi, Elizabeth

2018-03-01

Objectives In 2013, Kenya removed delivery fees at public health facilities in an effort to promote equity in access to health services and address high maternal mortality. This study determines the effect of the policy to remove user fees on institutional delivery in a population-based sample of women from urban Kenya. Methods Longitudinal data were collected from a representative sample of 8500 women from five cities in Kenya in 2010 with a follow-up interview in 2014 (response rate 58.9%). Respondents were asked about their most recent birth since 2008 at baseline and 2012 at endline, including the delivery location. Multinomial logistic regression is used, controlling for the temporal time trend and background characteristics, to determine if births which occurred after the national policy change were more likely to occur at a public facility than at home or a private facility. Results Multivariate findings show that women were significantly more likely to deliver at a public facility as compared to a private facility after the policy. Among the poor, the results show that poor women were significantly more likely to deliver in a public facility compared to home or a private facility after policy change. Conclusions for Practice These findings show Kenya's progress towards achieving universal access to delivery services and meeting its national development targets. The removal of delivery fees in the public sector is leading to increased use of facilities for delivery among the urban poor; this is an important first step in reducing maternal death.

Risk factors associated with neonatal deaths: a matched case-control study in Indonesia.

PubMed

Abdullah, Asnawi; Hort, Krishna; Butu, Yuli; Simpson, Louise

2016-01-01

Similar to global trends, neonatal mortality has fallen only slightly in Indonesia over the period 1990-2010, with a high proportion of deaths in the first week of life. This study aimed to identify risk factors associated with neonatal deaths of low and normal birthweight infants that were amenable to health service intervention at a community level in a relatively poor province of Indonesia. A matched case-control study of neonatal deaths reported from selected community health centres (puskesmas) was conducted over 10 months in 2013. Cases were singleton births, born by vaginal delivery, at home or in a health facility, matched with two controls satisfying the same criteria. Potential variables related to maternal and neonatal risk factors were collected from puskesmas medical records and through home visit interviews. A conditional logistic regression was performed to calculate odds ratios using the clogit procedure in Stata 11. Combining all significant variables related to maternal, neonatal, and delivery factors into a single multivariate model, six factors were found to be significantly associated with a higher risk of neonatal death. The factors identified were as follows: neonatal complications during birth; mother noting a health problem during the first 28 days; maternal lack of knowledge of danger signs for neonates; low Apgar score; delivery at home; and history of complications during pregnancy. Three risk factors (neonatal complication at delivery; neonatal health problem noted by mother; and low Apgar score) were significantly associated with early neonatal death at age 0-7 days. For normal birthweight neonates, three factors (complications during delivery; lack of early initiation of breastfeeding; and lack of maternal knowledge of neonatal danger signs) were found to be associated with a higher risk of neonatal death. The study identified a number of factors amenable to health service intervention associated with neonatal deaths in normal and low birthweight infants. These factors include maternal knowledge of danger signs, response to health problems noted by parents in the first month, early initiation of breastfeeding, and delivery at home. Addressing these factors could reduce neonatal deaths in low resource settings.

Associations between social and environmental factors and perinatal mortality in Jamaica.

PubMed

Golding, J; Greenwood, R; McCaw-Binns, A; Thomas, P

1994-04-01

Social and environmental factors in Jamaica were compared between 9919 mothers delivering in a 2-month period a singleton who survived the early neonatal period and 1847 mothers who were delivered of a singleton perinatal death in a contiguous 12-month period. Logistic regression showed independent positive statistically significant increased odds of having a perinatal death among mothers who lived in rural parishes, older mothers (aged 30 +), single parents, no other children in the household, large number of adults in the household, mother unemployed, the major wage earner of the household not being in a managerial, professional or skilled non-manual occupation, the household not having sole use of toilet facilities, smaller mothers and those classified as obese or undernourished. Variations were found for different categories of death. Intrapartum asphyxia deaths were not related to union (marital) status, occupation of major wage earner, number of adults nor to the use of the toilet. Antepartum fetal deaths did not vary significantly with occupation of major wage earner or maternal height, but did show a relationship with maternal education, mothers with lowest levels having reduced risk. Deaths from immaturity were significantly related only to occupation of major wage earner, number of children in the household, number of social amenities available (negative relationships) and maternal age (< 17 at highest risk). In conclusion there was little to indicate that social deprivation per se was related to perinatal death, although specific features of the environment showed strong relationships.

Effect of a facility-based multifaceted intervention on the quality of obstetrical care: a cluster randomized controlled trial in Mali and Senegal

PubMed Central

2013-01-01

Background Maternal mortality in referral hospitals in Mali and Senegal surpasses 1% of obstetrical admissions. Poor quality obstetrical care contributes to high maternal mortality; however, poor care is often linked to insufficient hospital resources. One promising method to improve obstetrical care is maternal death review. With a cluster randomized trial, we assessed whether an intervention, based on maternal death review, could improve obstetrical quality of care. Methods The trial began with a pre-intervention year (2007), followed by two years of intervention activities and a post-intervention year. We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit (CBCA). We collected data from 32 of the 46 trial hospitals (16 in each trial arm) and included 658 patients admitted to the maternity unit with a trial of labour. The CBCA questionnaire measured 5 dimensions of care- patient history, clinical examination, laboratory examination, delivery care and postpartum monitoring. We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material resources affect quality of care differences associated with the intervention. Results For all women, the mean percentage of care criteria met was 66.3 (SD 13.5). There were significantly greater mean CBCA scores in women treated at intervention hospitals (68.2) compared to control hospitals (64.5). After adjustment, women treated at intervention sites had 5 points’ greater scores than those at control sites. This difference was mostly attributable to greater clinical examination and post-partum monitoring scores. The association between the intervention and quality of care was the same, irrespective of the level of resources available to a hospital; however, as resources increased, so did quality of care scores in both arms of the trial. Trial registration The QUARITE trial is registered on the Current Controlled Trials website under ISRCTN46950658 PMID:23351269

Why do pregnant women die? A review of maternal deaths from 1990 to 2010 at the University of Alabama at Birmingham.

PubMed

Frölich, Michael A; Banks, Catiffaney; Brooks, Amber; Sellers, Alethia; Swain, Ryan; Cooper, Lauren

2014-11-01

The number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to a high of 17.8 deaths per 100,000 live births in 2009. Compared to Caucasian women, African American women were nearly 4 times as likely to die from childbirth. To better understand the reason for this trend, we conducted a case-control study at University of Alabama at Birmingham (UAB) Hospital. Our primary study hypothesis was that women who died at UAB were more likely to be African American than women in a control group who delivered an infant at UAB and did not die. We expected to find a difference in race proportions and other patient characteristics that would further help to elucidate the cause of a racial disparity in maternal deaths. We reviewed all maternal deaths (cases) at UAB Hospital from January 1990 through December 2010 identified based on electronic uniform billing data and ICD-9 codes. Each maternal death was matched 2:1 with women who delivered at a time that most closely coincided with the time of the maternal death in 2-step selection process (electronic identification and manual confirmation). Maternal variables obtained were comorbidities, duration of hospital stay, cause of death, race, distance from home to hospital, income, prenatal care, body mass index, parity, insurance type, mode of delivery, and marital status. The strength of univariate associations of maternal variables and case/control status was calculated. The association of case/control status and race was also examined after controlling for residential distance from the hospital. There was insufficient evidence to suggest racial disparity in maternal death. The proportion of African American women was 57% (42 of 77) in the maternal death group and 61% (94 of 154) in the control group (P = 0.23). The univariate odds ratio for maternal death for African American to Caucasian race was 0.66 (95% confidence interval [CI], 0.37-1.19); the adjusted odds ratio was 1.46 (95% CI, 0.73-3.01). Longer compared with shorter distance of residence to the hospital was a highly significant predictor (P < 0.001) of maternal death. We did not observe a racial disparity in maternal deaths at UAB Hospital. We suggest that the next step toward understanding racial differences in maternal deaths reported in the United States should be directed at the health care delivery outside the tertiary care hospital setting, particularly at eliminating access barriers to health care for all women.

[Maternal deaths related to social vulnerabilities. Results from the French confidential enquiry into maternal deaths, 2010-2012].

PubMed

Tessier, V; Leroux, S; Guseva-Canu, I

2017-12-01

The theme of deprivation is new for the ENCMM. In view of the perceived increase in the number of maternal deaths that may be related to a deprivation situation, we sought to understand the main dimensions that could contribute to maternal death in this context, in order to propose a definition. The selection of cases made a posteriori is mainly based on a qualitative judgment. Between 2010 and 2012, among the deaths evaluated by the CNEMM, one or more elements related to social vulnerability were identified in 8.6% of the cases (18 deaths). The direct criteria used were the concepts of "deprivation" or "social difficulties", difficulties of housing, language barriers and isolation. The absence of prenatal care was retained as an indirect marker. We excluded cases where psychiatric pathology and/or addiction were predominant. Of the 18 cases identified with deprivation factors, death was considered "unavoidable" in 2 cases (11%), "certainly avoidable" or "possibly avoidable" in 13 cases (72%). In 3 cases (17%), avoidability could not be determined. Avoidability was related to the content and adequacy of care in 11 cases out of 13 (85%) and the patient's interaction with the health care system in 10 of 18 cases (56%). The analysis of maternal deaths among women in precarious situations points out that the link between socio-economic deprivation and poor maternal health outcomes potentially includes a specific risk of maternal death. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Complications of induced abortion and miscarriage in three African countries: a hospital-based study among WHO collaborating centers.

PubMed

Goyaux, N; Alihonou, E; Diadhiou, F; Leke, R; Thonneau, P F

2001-06-01

The aim of this study was to describe two of the outcomes of pregnancy, induced abortion and miscarriage, in three African countries. Major maternal risk factors were also evaluated. The study was prospective and based on the medical files of all 1,957 women admitted to participating health care structures. Overall, 988 women were admitted for complications of miscarriage, and 969 for complications of induced abortion. Gestational age was lower in women with miscarriages (p<0.002). The level of use of contraceptive methods ((p<0.003) and educational level ((p<0.005) were lower in women who had had an induced abortion. In our study, 26 maternal deaths were recorded, 22 of which were associated with induced abortion. Infection was the most important risk factor for death (OR=4.8; 1.9-12.4). Maternal deaths related to abortion complications often occurred shortly after hospital admission and with signs of sepsis. This demonstrates the importance of effective emergency services. Unfortunately, hospital-based studies alone cannot assess all maternal death risk factors, especially those for maternal death related to induced abortion complications. It is therefore important to determine what happened to the woman before hospital admission and during her stay in hospital. Combinations of qualitative and quantitative methods could be used to increase our understanding of this problem and to help us to solve it.

Barriers to formal emergency obstetric care services' utilization.

PubMed

Essendi, Hildah; Mills, Samuel; Fotso, Jean-Christophe

2011-06-01

Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women's access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on "public relations" could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.

Impact of Place of Delivery on Neonatal Mortality in Rural Tanzania

PubMed Central

Ajaari, Justice; Masanja, Honorati; Weiner, Renay; Abokyi, Shalom Akonvi; Owusu-Agyei, Seth

2012-01-01

Objectives Studies on factors affecting neonatal mortality have rarely considered the impact of place of delivery on neonatal mortality. This study provides epidemiological information regarding the impact of place of delivery on neonatal deaths. Methods We analyzed data from the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania. A total of 5,124 live births and 166 neonatal deaths were recorded from January 2005 to December 2006. The place of delivery was categorized as either in a health facility or outside, and the neonatal mortality rate (NMR) was calculated as the number of neonatal deaths per 1,000 live births. Univariate and multivariate logistic regression models were used to assess the association between neonatal mortality and place of delivery and other maternal risk factors while adjusting for potential confounders. Results Approximately 67% (111) of neonatal deaths occurred during the first week of life. There were more neonatal deaths among deliveries outside health facilities (NMR = 43.4 per 1,000 live births) than among deliveries within health facilities (NMR = 27.0 per 1,000 live births). The overall NMR was 32.4 per 1,000 live births. Mothers who delivered outside a health facility experienced 1.85 times higher odds of experiencing neonatal deaths (adjusted odds ratio = 1.85; 95% confidence interval = 1.33−2.58) than those who delivered in a health facility. Conclusions and Public Health Implications Place of delivery is a significant predictor of neonatal mortality. Pregnant women need to be encouraged to deliver at health facilities and this should be done by intensifying education on where to deliver. Infrastructure, such as emergency transport, to facilitate health facility deliveries also requires urgent attention. PMID:27621958

Evaluating Facility-Based Decision-Making in Women with a Prior Cesarean Delivery and Association with Maternal and Perinatal Outcomes.

PubMed

Boatin, Adeline Adwoa; Adu-Bonsaffoh, Kwame; Wylie, Blair Johnson; Obed, Samuel A

2017-09-01

Objective To describe facility-based decision-making for women with one prior cesarean delivery (CD) in a resource-limited setting and to characterize maternal and perinatal outcomes in these groups. Methods One year retrospective study of women with one prior CD delivering at Korle-Bu Teaching Hospital (KBTH), Ghana. Women were categorized into three groups based on initial plan of management on admission [trial of labor after cesarean (TOLAC), emergency repeat CD (EMCD) or non-emergent repeat CD (RCD)]. Characteristics and outcomes across these groups were then compared. Results During the study period, 1247 women with one prior CD delivered at KBTH, of which 377 (30.2%) were triaged to RCD, 439 (35.2%) to EMCD and 431 (34.6%) to TOLAC. Twelve uterine ruptures and no maternal deaths occurred. Perinatal mortality was 4.2% (n = 52). Compared to the RCD group, the TOLAC group had a lower risk for maternal adverse events (aOR 0.3, 95% CI 0.1-1.0; p = 0.04) and non-significant higher risk of perinatal adverse events (aOR 1.6, 95% CI 0.7-3.3; p = 0.25). Compared to women triaged to RCD, the EMCD group had a non-significant increase in risk of maternal adverse events (aOR 1.6, 95% CI 0.8-3.5; p = 0.2) and a significantly higher rate of perinatal adverse events (aOR 2.4, 95% CI 1.2-4.9; p = 0.01). Conclusions for Practice Women triaged to EMCD at admission are different when compared to women allowed a TOLAC or offered a non-emergent RCD. These women bear increased rates of adverse outcomes and should be considered as a separate group for analysis in future studies conducted in similar settings.

The Alliance for Innovation in Maternal Health Care: A Way Forward.

PubMed

Mahoney, Jeanne

2018-06-01

The Alliance for Innovation in Maternal Health is a program supported by the Health Services Resource Administration to reduce maternal mortality and severe maternal morbidity in the United States. This program develops bundles of evidence based action steps for birth facilities to adapt. Progress is monitored at the facility, state and national levels to foster data-driven quality improvement efforts.

Linking families and facilities for care at birth: What works to avert intrapartum-related deaths?

PubMed Central

Lee, Anne CC; Lawn, Joy E.; Cousens, Simon; Kumar, Vishwajeet; Osrin, David; Bhutta, Zulfiqar A.; Wall, Steven N.; Nandakumar, Allyala K.; Syed, Uzma; Darmstadt, Gary L.

2012-01-01

Background Delays in receiving effective care during labor and at birth may be fatal for the mother and fetus, contributing to 2 million annual intrapartum stillbirths and intrapartum-related neonatal deaths each year. Objective We present a systematic review of strategies to link families and facilities, including community mobilization, financial incentives, emergency referral and transport systems, prenatal risk screening, and maternity waiting homes. Results There is moderate quality evidence that community mobilization with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality. Meta-analysis showed a doubling of skilled birth attendance and a 35% reduction in early neonatal mortality. However, no data are available on intrapartum-specific outcomes. Evidence is limited, but promising, that financial incentive schemes and community referral/transport systems may increase rates of skilled birth attendance and emergency obstetric care utilization; however, impact on mortality is unknown. Current evidence for maternity waiting homes and risk screening is low quality. Conclusions Empowering communities is an important strategy to reduce the large burden of intrapartum complications. Innovations are needed to bring the poor closer to obstetric care, such as financial incentives and cell phone technology. New questions need to be asked of “old” strategies such as risk screening and maternity waiting homes. The effect of all of these strategies on maternal and perinatal mortality, particularly intrapartum-related outcomes, requires further evaluation. PMID:19815201

Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis.

PubMed

Elmusharaf, Khalifa; Byrne, Elaine; AbuAgla, Ayat; AbdelRahim, Amal; Manandhar, Mary; Sondorp, Egbert; O'Donovan, Diarmuid

2017-08-29

Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility. This study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software. Once the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care. Our findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.

A Review of Pregnancy-Related Maternal Mortality in Wisconsin, 2006-2010.

PubMed

Schellpfeffer, Michael A; Gillespie, Kate H; Rohan, Angela M; Blackwell, Sarah P

2015-10-01

Maternal mortality is a key indicator of maternal health and the general state of health care. This report summarizes maternal deaths in Wisconsin from January 2006 through December 2010. Maternal deaths were identified using death certificates and supporting links with infant birth and fetal death certificates. Suspected pregnancy-related maternal deaths were abstracted by a Wisconsin Maternal Mortality Review Team nurse abstractor. The entire team reviewed and analyzed these cases. If the death was deemed pregnancy related, a cause of death was determined, potential factors of avoidability were assessed, and recommendations for possible quality improvement were made. Fifty cases were reviewed and 21 cases were determined to be pregnancy related. The Wisconsin pregnancy-related maternal mortality ratio was 5.9 deaths per 100,000 live births (3.9-9.0, 95% CI), with markedly higher rates for non-Hispanic black women. The most common cause of death was cardiovascular related, with 5 of the 7 deaths being ascribed to peripartum cardiomyopathy. Chronic medical problems were associated with 55% of pregnancy-related maternal deaths excluding obesity. Nineteen percent of the pregnancy-related deaths reviewed were considered to be avoidable, and almost half (48%) had substantive recommendations made to improve maternal health. Even though the Wisconsin pregnancy-related maternal mortality ratio is well below the national average, there remain stark racial disparities in maternal deaths and a number of avoidable pregnancy-related deaths that should be targeted for prevention.

Causes of death in Vanuatu.

PubMed

Carter, Karen; Tovu, Viran; Langati, Jeffrey Tila; Buttsworth, Michael; Dingley, Lester; Calo, Andy; Harrison, Griffith; Rao, Chalapati; Lopez, Alan D; Taylor, Richard

2016-01-01

The population of the Pacific Melanesian country of Vanuatu was 234,000 at the 2009 census. Apart from subsistence activities, economic activity includes tourism and agriculture. Current completeness of vital registration is considered too low to be usable for national statistics; mortality and life expectancy (LE) are derived from indirect demographic estimates from censuses/surveys. Some cause of death (CoD) data are available to provide information on major causes of premature death. Deaths 2001-2007 were coded for cause (ICDv10) for ages 0-59 years from: hospital separations (HS) (n = 636), hospital medical certificates (MC) of death (n = 1,169), and monthly reports from community health facilities (CHF) (n = 1,212). Ill-defined causes were 3 % for hospital deaths and 20 % from CHF. Proportional mortality was calculated by cause (excluding ill-defined) and age group (0-4, 5-14 years), and also by sex for 15-59 years. From total deaths by broad age group and sex from 1999 and 2009 census analyses, community deaths were estimated by deduction of hospital deaths MC. National proportional mortality by cause was estimated by a weighted average of MC and CHF deaths. National estimates indicate main causes of deaths <5 years were: perinatal disorders (45 %) and malaria, diarrhea, and pneumonia (27 %). For 15-59 years, main causes of male deaths were: circulatory disease 27 %, neoplasms 13 %, injury 13 %, liver disease 10 %, infection 10 %, diabetes 7 %, and chronic respiratory disease 7 %; and for females: neoplasms 29 %, circulatory disease 15 %, diabetes 10 %, infection 9 %, and maternal deaths 8 %. Infection included tuberculosis, malaria, and viral hepatitis. Liver disease (including hepatitis and cancer) accounted for 18 % of deaths in adult males and 9 % in females. Non-communicable disease (NCD), including circulatory disease, diabetes, neoplasm, and chronic respiratory disease, accounted for 52 % of premature deaths in adult males and 60 % in females. Injuries accounted for 13 % in adult males and 6 % in females. Maternal deaths translate into an annual maternal mortality ratio of 130/100,000 for the period. Vanuatu manifests a double burden of disease with significant proportional mortality from perinatal disorders and infection/pneumonia <5 years and maternal mortality, coupled with significant proportional mortality in adults (15-59 years) from cardiovascular disease (CVD), neoplasms, and diabetes.

Maternal mortality in Syria: causes, contributing factors and preventability.

PubMed

Bashour, Hyam; Abdulsalam, Asmaa; Jabr, Aisha; Cheikha, Salah; Tabbaa, Mohammed; Lahham, Moataz; Dihman, Reem; Khadra, Mazen; Campbell, Oona M R

2009-09-01

To describe the biomedical and other causes of maternal death in Syria and to assess their preventability. A reproductive age mortality study (RAMOS) design was used to identify pregnancy related deaths. All deaths among women aged 15-49 reported to the national civil register for 2003 were investigated through home interviews. Verbal autopsies were used to ascertain the cause of death among pregnancy related maternal deaths, and causes and preventability of deaths were assessed by a panel of doctors. A total of 129 maternal deaths were identified and reviewed. Direct medical causes accounted for 88%, and haemorrhage was the main cause of death (65%). Sixty nine deaths (54%) occurred during labour or delivery. Poor clinical skills and lack of clinical competency were behind 54% of maternal deaths. Ninety one percent of maternal deaths were preventable. The causes of maternal death in Syria and their contributing factors reflect serious defects in the quality of maternal care that need to be urgently rectified.

Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial.

PubMed

Zongo, Augustin; Dumont, Alexandre; Fournier, Pierre; Traore, Mamadou; Kouanda, Séni; Sondo, Blaise

2015-02-01

To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings. We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not pre-specified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192). The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p=0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p=0.6213). This differential effect was particularly marked for district hospitals. Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

One in Five Maternal Deaths in Bangladesh Associated with Acute Jaundice: Results from a National Maternal Mortality Survey

PubMed Central

Shah, Rupal; Nahar, Quamrun; Gurley, Emily S.

2016-01-01

We estimated the proportion of maternal deaths in Bangladesh associated with acute onset of jaundice. We used verbal autopsy data from a nationally representative maternal mortality survey to calculate the proportion of maternal deaths associated with jaundice and compared it to previously published estimates. Of all maternal deaths between 2008 and 2010, 23% were associated with jaundice, compared with 19% from 1998 to 2001. Approximately one of five maternal deaths was preceded by jaundice, unchanged in 10 years. Our findings highlight the need to better understand the etiology of these maternal deaths in Bangladesh. PMID:26755563

The experiences of women with maternal near miss and their perception of quality of care in Kelantan, Malaysia: a qualitative study.

PubMed

Norhayati, Mohd Noor; Nik Hazlina, Nik Hussain; Asrenee, Ab Razak; Sulaiman, Zaharah

2017-06-15

Maternal mortality has been the main way of ascertaining the outcome of maternal and obstetric care. However, maternal morbidities occur more frequently than maternal deaths; therefore, maternal near miss was suggested as a more useful indicator for the evaluation and improvement of maternal health services. Our study aimed to explore the experiences of women with maternal near miss and their perception of the quality of care in Kelantan, Malaysia. A qualitative phenomenological approach with in-depth interview method was conducted in two tertiary hospitals in Kelantan, Malaysia. All women admitted to labour room, obstetrics and gynaecology wards and intensive care units in 2014 were screened for the presence of any vital organ dysfunction or failure based on the World Health Organization criteria for maternal near miss. Pregnancy irrespective of the gestational age was included. Women younger than 18 years old, with psychiatric disorder and beyond 42 days of childbirth were excluded. Thirty women who had experienced maternal near miss events were included in the analysis. All were Malays between the ages of 22 and 45. Almost all women (93.3%) had secondary and tertiary education and 63.3% were employed. The women's perceptions of the quality of their care were influenced by the competency and promptness in the provision of care, interpersonal communication, information-sharing and the quality of physical resources. The predisposition to seek healthcare was influenced by costs, self-attitude and beliefs. Self-appraisal of maternal near miss, their perception of the quality of care, their predisposition to seek healthcare and the social support received were the four major themes that emerged from the experiences and perceptions of women with maternal near miss. The women with maternal near miss viewed their experiences as frightening and that they experienced other negative emotions and a sense of imminent death. The factors influencing women's perceptions of quality of care should be of concern to those seeking to improve services at healthcare facilities. The addition of a maternal near miss case review programme, allows for understanding on the factors related to providing care or to the predisposition to seek care; if addressed, may improve future healthcare and patient outcomes.

Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the Global Network's EmONC trial).

PubMed

Pasha, Omrana; Goldenberg, Robert L; McClure, Elizabeth M; Saleem, Sarah; Goudar, Shivaprasad S; Althabe, Fernando; Patel, Archana; Esamai, Fabian; Garces, Ana; Chomba, Elwyn; Mazariegos, Manolo; Kodkany, Bhala; Belizan, Jose M; Derman, Richard J; Hibberd, Patricia L; Carlo, Waldemar A; Liechty, Edward A; Hambidge, K Michael; Buekens, Pierre; Wallace, Dennis; Howard-Grabman, Lisa; Stalls, Suzanne; Koso-Thomas, Marion; Jobe, Alan H; Wright, Linda L

2010-12-14

Maternal and newborn mortality rates remain unacceptably high, especially where the majority of births occur in home settings or in facilities with inadequate resources. The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes. However, the effectiveness of emergency obstetric and neonatal care services has never been proven. Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes. We have developed a cluster-randomized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization, birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities. This trial will take place in 106 clusters (300-500 deliveries per year each) across 7 sites of the Global Network for Women's and Children's Health Research in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. The trial intervention has three key elements, community mobilization, home-based life saving skills for communities and birth attendants, and training of providers at obstetric facilities to improve quality of care. The primary outcome of the trial is perinatal mortality. Secondary outcomes include rates of stillbirth, 7-day neonatal mortality, maternal death or severe morbidity (including obstetric fistula, eclampsia and obstetrical sepsis) and 28-day neonatal mortality. In this trial, we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes. If successful, the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries. ClinicalTrials.gov NCT01073488.

Effect of Free Maternal Health Care Program on Health-seeking Behaviour of Women during Pregnancy, Intra-partum and Postpartum Periods in Cross River State of Nigeria: A Mixed Method Study.

PubMed

Edu, Betta Chimaobim; Agan, Thomas U; Monjok, Emmanuel; Makowiecka, Krystyna

2017-06-15

Increasing the percentage of maternal health service utilization in health facilities, through cost-removal policy is important in reducing maternal deaths. The Cross River State Government of Nigeria introduced a cost-removal policy in 2009, under the umbrella of "PROJECT HOPE" where free maternal health services are provided. Since its inception, there has been no formal evaluation of its effectiveness. This study aims to evaluate the effect of the free maternal health care program on the health care-seeking behaviours of pregnant women in Cross River State, Nigeria. A mixed method approach (quantitative and qualitative methods) was used to describe the effect of free maternal health care intervention. The quantitative component uses data on maternal health service utilisation obtained from PROJECT HOPE and Nigeria Demographic Health Survey. The qualitative part uses Focus Group Discussions to examine women's perception of the program. Results suggest weak evidence of change in maternal health care service utilization, as 95% Confidence Intervals overlap even though point estimate suggest increase in utilization. Results of quantitative data show increase in the percentage of women accessing maternal health services. This increase is greater than the population growth rate of Cross River State which is 2.9%, from 2010 to 2013. This increase is likely to be a genuine increase in maternal health care utilisation. Qualitative results showed that women perceived that there have been increases in the number of women who utilize Antenatal care, delivery and Post Partum Care at health facilities, following the removal of direct cost of maternal health services. There is urban and rural differences as well as between communities closer to health facility and those further off. Perceived barriers to utilization are indirect cost of service utilization, poor information dissemination especially in rural areas, perceived poor quality of care at facilities including drug and consumables stock-outs, geographical barriers, inadequate health work force, and poor attitude of skilled health workers and lack of trust in the health system. Reasons for Maternal health care utilisation even under a cost-removal policy is multi-factorial. Therefore, in addition to fee-removal, the government must be committed to addressing other deterrents so as to significantly increase maternal health care service utilisation.

Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu.

PubMed

Vora, Kranti Suresh; Koblinsky, Sally A; Koblinsky, Marge A

2015-07-31

India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu. Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat. Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.

The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature.

PubMed

Neal, Sarah; Mahendra, Shanti; Bose, Krishna; Camacho, Alma Virginia; Mathai, Matthews; Nove, Andrea; Santana, Felipe; Matthews, Zoë

2016-11-11

While the main causes of maternal mortality in low and middle income countries are well understood, less is known about whether patterns for causes of maternal deaths among adolescents are the same as for older women. This study systematically reviews the literature on cause of maternal death in adolescence. Where possible we compare the main causes for adolescents with those for older women to ascertain differences and similarity in mortality patterns. An initial search for papers and grey literature in English, Spanish and Portuguese was carried out using a number of electronic databases based on a pre-determined search strategy. The outcome of interest was the proportion of maternal deaths amongst adolescents by cause of death. A total of 15 papers met the inclusion criteria established in the study protocol. The main causes of maternal mortality in adolescents are similar to those of older women: hypertensive disorders, haemorrhage, abortion and sepsis. However some studies indicated country or regional differences in the relative magnitudes of specific causes of adolescent maternal mortality. When compared with causes of death for older women, hypertensive disorders were found to be a more important cause of mortality for adolescents in a number of studies in a range of settings. In terms of indirect causes of death, there are indications that malaria is a particularly important cause of adolescent maternal mortality in some countries. The main causes of maternal mortality in adolescents are broadly similar to those for older women, although the findings suggest some heterogeneity between countries and regions. However there is evidence that the relative importance of specific causes may differ for this younger age group compared to women over the age of 20 years. In particular hypertensive conditions make up a larger share of maternal deaths in adolescents than older women. Further, large scale studies are needed to investigate this question further.

Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone.

PubMed

Ramanathan, Aparna; Eckardt, Melody J; Nelson, Brett D; Guha, Moytrayee; Oguttu, Monica; Altawil, Zaid; Burke, Thomas

2018-05-15

Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. The ESM-UBT device appears safe for use in women with uncontrolled PPH. Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit.

Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

PubMed Central

2017-01-01

Summary Background In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015. Methods We estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10–54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Findings Only ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic pregnancy, and/or miscarriage. Historical patterns suggest achievement of SDG 3.1 will require 91% coverage of one antenatal care visit, 78% of four antenatal care visits, 81% of in-facility delivery, and 87% of skilled birth attendance. Interpretation Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population. Funding Bill & Melinda Gates Foundation. PMID:27733286

One in Five Maternal Deaths in Bangladesh Associated with Acute Jaundice: Results from a National Maternal Mortality Survey.

PubMed

Shah, Rupal; Nahar, Quamrun; Gurley, Emily S

2016-03-01

We estimated the proportion of maternal deaths in Bangladesh associated with acute onset of jaundice. We used verbal autopsy data from a nationally representative maternal mortality survey to calculate the proportion of maternal deaths associated with jaundice and compared it to previously published estimates. Of all maternal deaths between 2008 and 2010, 23% were associated with jaundice, compared with 19% from 1998 to 2001. Approximately one of five maternal deaths was preceded by jaundice, unchanged in 10 years. Our findings highlight the need to better understand the etiology of these maternal deaths in Bangladesh. © The American Society of Tropical Medicine and Hygiene.

A Large-Scale Internet/Computer-Based, Training Module: Dissemination of Evidence-Based Management of Postpartum Hemorrhage to Front-Line Health Care Workers

ERIC Educational Resources Information Center

Abawi, Karim; Gertiser, Lynn; Idris, Raqibat; Villar, José; Langer, Ana; Chatfield, Alison; Campana, Aldo

2017-01-01

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in most developing and low-income countries and the cause of one-quarter of maternal deaths worldwide. With appropriate and prompt care, these deaths can be prevented. With the current and rapidly developing research and worldwide access to information, a lack of knowledge of…

Estimation of maternal and neonatal mortality at the subnational level in Liberia.

PubMed

Moseson, Heidi; Massaquoi, Moses; Bawo, Luke; Birch, Linda; Dahn, Bernice; Zolia, Yah; Barreix, Maria; Gerdts, Caitlin

2014-11-01

To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method. The status of maternal and neonatal health in Bomi County, Liberia, was investigated in June 2013 using a population-based survey (n=1985). The standard direct sisterhood method was modified to account for place and time of maternal death to enable calculation of subnational estimates. The modified method of measuring maternal mortality successfully enabled the calculation of area-specific estimates. Of 71 reported deaths of sisters, 18 (25.4%) were due to pregnancy-related causes and had occurred in the past 3 years in Bomi County. The estimated maternal mortality ratio was 890 maternal deaths for every 100 000 live births (95% CI, 497-1301]. The neonatal mortality rate was estimated to be 47 deaths for every 1000 live births (95% CI, 42-52). In total, 322 (16.9%) of 1900 women with accurate age data reported having had a stillbirth. The modified direct sisterhood method may be useful to other countries seeking a more regionally nuanced understanding of areas in which neonatal and maternal mortality levels still need to be reduced to meet Millennium Development Goals. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial.

PubMed

Bhutta, Zulfiqar A; Soofi, Sajid; Cousens, Simon; Mohammad, Shah; Memon, Zahid A; Ali, Imran; Feroze, Asher; Raza, Farrukh; Khan, Amanullah; Wall, Steve; Martines, Jose

2011-01-29

Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. 16 clusters were assigned to intervention (23,353 households, 12,391 total births) and control groups (23,768 households, 11,443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12,028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68-0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76-0·96; p=0·02). Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential. WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation. Copyright © 2011 Elsevier Ltd. All rights reserved.

Economic Impact of Maternal Death on Households in Rural China: A Prospective Cohort Study

PubMed Central

Wang, Yan; Huntington, Dale

2013-01-01

Objective To assess the economic impact of maternal death on rural Chinese households during the year after maternal death. Methods A prospective cohort study matched 183 households who had suffered a maternal death to 346 households that experienced childbirth without maternal death in rural areas of three provinces in China. Surveys were conducted at baseline (1–3 months after maternal death or childbirth) and one year after baseline using the quantitative questionnaire. We investigated household income, expenditure, accumulated debts, and self-reported household economic status. Difference-in-Difference (DID), linear regression, and logistic regression analyses were used to compare the economic status between households with and without maternal death. Findings The households with maternal death had a higher risk of self-reported “household economy became worse” during the follow-up period (adjusted OR = 6.04, p<0.001). During the follow-up period, at the household level, DID estimator of income and expenditure showed that households with maternal death had a significant relative reduction of US$ 869 and US$ 650, compared to those households that experienced childbirth with no adverse event (p<0.001). Converted to proportions of change, an average of 32.0% reduction of annual income and 24.9% reduction of annual expenditure were observed in households with a maternal death. The mean increase of accumulated debts in households with a maternal death was 3.2 times as high as that in households without maternal death (p = 0.024). Expenditure pattern of households with maternal death changed, with lower consumption on food (p = 0.037), clothes and commodity (p = 0.003), traffic and communication (p = 0.022) and higher consumption on cigarette or alcohol (p = 0.014). Conclusion Compared with childbirth, maternal death had adverse impact on household economy, including higher risk of self-reported “household economy became worse”, decreased income and expenditure, increased debts and changed expenditure pattern. PMID:24204648

Determinants of maternal mortality: a hospital based study from south India.

PubMed

Rajaram, P; Agrawal, A; Swain, S

1995-01-01

During 1981-1986, 86 maternal deaths transpired at the obstetrics department of the Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India. The maternal mortality rate stood at 5.8/1000 births. 31.4% were primigravidae. The percentage of maternal deaths characterized as gravidae 2-4, 5, and multigravidae was 42.9%, 9.3%, and 16.4%, respectively. The leading causes of death were sepsis (41.9%), especially septic abortion (30.2%); eclampsia-severe preeclampsia (10.5%); ruptured uterus (9.3%); and hemorrhage and prolonged labor (8.1% each). Direct obstetric causes of death accounted for 81.4% of all maternal deaths. Indirect obstetric causes of death were hepatitis (5.8%), heart disease (4.7%), and severe anemia (2.3%). Most of the women who died were illiterate (97.6%), poor (98.8%), and had received no prenatal care (94.2%). 47.7% traveled more than 60 km to the hospital. Quacks or untrained traditional birth attendants had excessively interfered with about 33% before they reached the hospital, especially the septic induced abortion, obstructed labor, and ruptured uterus cases. Among the 48 women who delivered before dying, there were 24 live births (5 of whom died during the early neonatal period) and 24 still births. These findings indicate a need for a cooperative effort to improve and expand maternal and child health care in the community.

Community perceptions of pre-eclampsia in rural Karnataka State, India: a qualitative study.

PubMed

Vidler, Marianne; Charantimath, Umesh; Katageri, Geetanjali; Ramadurg, Umesh; Karadiguddi, Chandrashekhar; Sawchuck, Diane; Qureshi, Rahat; Dharamsi, Shafik; von Dadelszen, Peter; Derman, Richard; Goudar, Shivaprasad; Mallapur, Ashalata; Bellad, Mrutyunjaya

2016-06-08

Maternal deaths have been attributed in large part to delays in recognition of illness, timely transport to facility, and timely treatment once there. As community perceptions of pregnancy and their complications are critical to averting maternal morbidity and mortality, this study sought to contribute to the literature and explore community-based understandings of pre-eclampsia and eclampsia. The study was conducted in rural Karnataka State, India, in 2012-2013. Fourteen focus groups were held with the following community stakeholders: three with community leaders (n = 27), two with male decision-makers (n = 19), three with female decision-makers (n = 41), and six with reproductive age women (n = 132). Focus groups were facilitated by local researchers with clinical and research expertise. Discussions were audio-recorded, transcribed verbatim and translated to English for thematic analysis using NVivo 10. Terminology exists in the local language (Kannada) to describe convulsions and hypertension, but there were no terms that are specific to pregnancy. Community participants perceived stress, tension and poor diet to be precipitants of hypertension in pregnancy. Seizures in pregnancy were thought to be brought on by anaemia, poor medical adherence, lack of tetanus toxoid immunization, and exposure in pregnancy to fire or water. Sweating, fatigue, dizziness-unsteadiness, swelling, and irritability were perceived to be signs of hypertension, which was recognized to have the potential to lead to eclampsia or death. Home remedies, such as providing the smell of onion, placing an iron object in the hands, or squeezing the fingers and toes, were all used regularly to treat seizures prior to accessing facility-based care although transport is not delayed. It is evident that 'pre-eclampsia' and 'eclampsia' are not well-known; instead hypertension and seizures are perceived as conditions that may occur during or outside pregnancy. Improving community knowledge about, and modifying attitudes towards, hypertension in pregnancy and its complications (including eclampsia) has the potential to address community-based delays in disease recognition and delays in treatment that contribute to maternal and perinatal morbidity and mortality. Advocacy and educational initiatives should be designed to target knowledge gaps and potentially harmful practices, and respond to cultural understandings of disease. NCT01911494.

Using community informants to estimate maternal mortality in a rural district in Pakistan: a feasibility study.

PubMed

Mir, Ali Mohammad; Shaikh, Mohammad Saleem; Qomariyah, Siti Nurul; Rashida, Gul; Khan, Mumraiz; Masood, Irfan

2015-01-01

We aimed to assess the feasibility of using community-based informants' networks to identify maternal deaths that were followed up through verbal autopsies (MADE-IN MADE-FOR technique) to estimate maternal mortality in a rural district in Pakistan. We used 4 community networks to identify deaths in women of reproductive age in the past 2 years in Chakwal district, Pakistan. The deaths recorded by the informants were followed up through verbal autopsies. In total 1,143 Lady Health Workers (government employees who provide primary health care), 1577 religious leaders, 20 female lady councilors (elected representatives), and 130 nikah registrars (persons who register marriages) identified 2001 deaths in women of reproductive age. 1424 deaths were followed up with verbal autopsies conducted with the relatives of the deceased. 169 pregnancy-related deaths were identified from all reported deaths. Through the capture-recapture technique probability of capturing pregnancy-related deaths by LHWs was 0.73 and for religious leaders 0.49. Maternal mortality in Chakwal district was estimated at 309 per 100,000 live births. It is feasible and economical to use community informants to identify recent deaths in women of reproductive age and, if followed up through verbal autopsies, obviate the need for conducting large scale surveys.

Over-the-counter MTP Pills and Its Impact on Women's Health.

PubMed

Sarojini; Ashakiran, T R; Bhanu, B T; Radhika

2017-02-01

To study the complications and consequences including maternal morbidity and mortality following indiscriminate self-consumption of abortion pills reporting to a tertiary care center. This is an observational study conducted at Vanivilas hospital between January 2012 to December 2013 for 24 months. After applying inclusion and exclusion criteria, 104 women were studied with respect to period of gestation, parity, clinical features at presentation and management in the institution. An analysis of maternal morbidity and mortality was done with respect to surgical interventions, ICU admissions, need for blood transfusions and maternal deaths. In this study, there were 75 (72.2 %) cases of incomplete abortion, 10 (9.6 %) cases of missed abortion, 2 (1.9 %) cases of ruptured ectopic and 2 (1.9 %) cases of rupture uterus. Seventy-eight (75 %) cases received blood transfusion, 7 (6.7 %) were admitted to ICU, and 2 (1.9 %) developed acute kidney injury. There were 2 (1.9 %) maternal deaths in the study group. This study shows urgent need for legislation and restriction of drugs used for medical termination of pregnancy. Drugs should be made available via health care facilities under supervision to reduce maternal mortality and morbidity due to indiscriminate use of these pills.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol.

PubMed

Kestler, Edgar; Walker, Dilys; Bonvecchio, Anabelle; de Tejada, Sandra Sáenz; Donner, Allan

2013-03-21

Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries. A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries. A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes. ClinicalTrial.gov,http://NCT01653626.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol

PubMed Central

2013-01-01

Background Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries. Methods/Design A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries. Discussion A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes. Trial registration ClinicalTrial.gov,http://NCT01653626. PMID:23517050

A meta-analysis of socio-demographic factors predicting birth in health facility.

PubMed

Berhan, Yifru; Berhan, Asres

2014-09-01

The low proportion of health facility delivery in developing countries is one of the main challenges in achieving the Millennium Development Goal of a global reduction of maternal deaths by 75% by 2015. There are several primary studies which identified socio-demographic and other predictors of birth in health facility. However, there are no efforts to synthesis the findings of these studies. The objective of this meta-analysis was to determine the strength of the association of birth in the health facility with selected sociodemographic factors. A meta-analysis of Mantel-Haenszel odds ratios was conducted by including 24 articles which were reported between 2000 and 2013 from developing countries. A computer-based search was done from MEDLINE, African Journals Online, Google Scholar and HINARI databases. Included studies did compare the women's' health facility delivery in relation to their selected socio-demographic characteristics. The pooled analysis demonstrated association of health facility delivery with living in urban areas (OR = 9.8), secondary and above educational level of the parents (OR = 5.0), middle to high wealth status (OR = 2.3) and first time pregnancy (OR = 2.8). The risk of delivering outside the health facility was not significantly associated with maternal age (teenage vs 20 years and above) and marital status. The distance of pregnant women's residence from the health facility was found to have an inverse relation to the proportion of health facility delivery. Although the present meta-analysis identified several variables which were associated with an increase in health facility delivery, the most important predictor of birth in the health facility amenable to intervention is educational status of the parents to be. Therefore, formal and informal education to women and family members on the importance of health facility delivery needs to be strengthened. Improving the wealth status of the population across the world may not be achieved soon, but should be in the long-term strategy to increase the birth rate in the health facility.

Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence.

PubMed

Madzimbamuto, Farai D; Ray, Sunanda; Mogobe, Keitshokile D

2013-06-10

The failure to reduce preventable maternal deaths represents a violation of women's right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks. Confidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman's death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women's lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients' rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques. In countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.

The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis.

PubMed

Kuwawenaruwa, August; Mtei, Gemini; Baraka, Jitihada; Tani, Kassimu

2016-11-18

Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services. A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries' education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women's decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants. Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home. To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as giving women insurance cards only does not guarantee facility-based delivery.

Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: results from nine states in India.

PubMed

Randive, Bharat; San Sebastian, Miguel; De Costa, Ayesha; Lindholm, Lars

2014-12-01

Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR). Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities. These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial.

PubMed

Dumont, Alexandre; Fournier, Pierre; Abrahamowicz, Michal; Traoré, Mamadou; Haddad, Slim; Fraser, William D

2013-07-13

Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali. We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658. 191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. Canadian Institutes of Health Research. Copyright © 2013 Elsevier Ltd. All rights reserved.

Pitfalls of national routine death statistics for maternal mortality study.

PubMed

Saucedo, Monica; Bouvier-Colle, Marie-Hélène; Chantry, Anne A; Lamarche-Vadel, Agathe; Rey, Grégoire; Deneux-Tharaux, Catherine

2014-11-01

The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths. National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described. Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians. Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study. © 2014 John Wiley & Sons Ltd.

Success in reducing maternal and child mortality in Afghanistan.

PubMed

Rasooly, Mohammad Hafiz; Govindasamy, Pav; Aqil, Anwer; Rutstein, Shea; Arnold, Fred; Noormal, Bashiruddin; Way, Ann; Brock, Susan; Shadoul, Ahmed

2014-01-01

After the collapse of the Taliban regime in 2002, Afghanistan adopted a new development path and billions of dollars were invested in rebuilding the country's economy and health systems with the help of donors. These investments have led to substantial improvements in maternal and child health in recent years and ultimately to a decrease in maternal and child mortality. The 2010 Afghanistan Mortality Survey (AMS) provides important new information on the levels and trends in these indicators. The AMS estimated that there are 327 maternal deaths for every 100,000 live births (95% confidence interval = 260-394) and 97 deaths before the age of five years for every 1000 children born. Decreases in these mortality rates are consistent with changes in key determinants of mortality, including an increasing age at marriage, higher contraceptive use, lower fertility, better immunisation coverage, improvements in the percentage of women delivering in health facilities and receiving antenatal and postnatal care, involvement of community health workers and increasing access to the Basic Package of Health Services. Despite the impressive gains in these areas, many challenges remain. Further improvements in health services in Afghanistan will require sustained efforts on the part of both the Government of Afghanistan and international donors.

The absence of birthweight paradox as a marker of disadvantages faced by low maternal education children.

PubMed

Guimarães, P V; Fonseca, S C; Pinheiro, R S; Aguiar, F P; Camargo, K R; Coeli, C M

2017-12-01

This study tested the hypothesis that the birthweight paradox would not be observed when assessing the effect of maternal education on neonatal mortality in the presence of socioeconomic inequality in access to health care. Non-concurrent cohort study. Passive follow-up of live-born infants using probabilistic record linkage of birth and death records for Rio de Janeiro (2004-2010; n = 1 445 367). Maternal age, birthweight and neonatal death were evaluated according to maternal educational level strata (<4, 4-11 and ≥12 years of study). We estimated the association between maternal educational level and neonatal mortality using logistical regression models adjusted for maternal age and birthweight (<2500 g and ≥2500 g). Neonatal mortality was 1.8 times higher in low educational level group compared with high educational level. We did not find birthweight-specific mortality curves crossing over in the stratum under 2500 g (birthweight paradox). The odds of a low birthweight child being born in facilities without neonatal intensive care units was about 70% higher in the group of low education when compared with mothers with high education. The absence of crossing birthweight-specific mortality curves may be a reason for concern about the severity of the disadvantages faced by low maternal education women. © The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Analysis of the equity of emergency medical services: a cross-sectional survey in Chongqing city.

PubMed

Liu, Yalan; Jiang, Yi; Tang, Shenglan; Qiu, Jingfu; Zhong, Xiaoni; Wang, Yang

2015-12-21

Due to reform of the economic system and the even distribution of available wealth, emergency medical services (EMS) experienced greater risks in equity. This study aimed to assess the equity of EMS needs, utilisation, and distribution of related resources, and to provide evidence for policy-makers to improve such services in Chongqing city, China. Five emergency needs variables (mortality rate of maternal, neonatal, cerebrovascular, cardiovascular, injury and poisoning) from the death surveillance, and two utilisation variables (emergency room visits and rate of utilisation) were collected from Chongqing Health Statistical Year Book 2008 to 2012. We used a concentration index (CI) to assess equality in the distribution of needs and utilisation among three areas with different per-head gross domestic product (GDP). In each area, we randomly chose two districts as sample areas and selected all the medical institutions with emergency services as subjects. We used the Gini coefficient (G) to measure equity in population and geographic distribution of facilities and human resources related EMS. Maternal-caused (CI: range -0.213 to -0.096) and neonatal-caused (CI: range -0.161 to -0.046)deaths declined in 2008-12, which focusing mainly on the less developed area. The maternal deaths were less equitably distributed than neonatal, and the gaps between areas gradually become more noticeable. For cerebrovascular (CI: range 0.106 to 0.455), cardiovascular (CI: range 0.101 to 0.329), injury and poisoning (CI: range 0.001 to 0.301) deaths, we documented a steady improvement of mortality; the overall equity of these mortalities was lower than those of maternal and neonatal mortalities, but distinct decreases were seen over time. The patients in developed area were more likely to use EMS (CI: range 0.296 to 0.423) than those in less developed area, and the CI increased over the 5-year period, suggesting that gaps in equity were increasing. The population distribution of facilities, physicians and nurses (G: range 0.2 to 0.3) was relatively equitable; the geographic distribution (G: range 0.4 to 0.5) showed a big gap between areas. In Chongqing city, equity of needs, utilization, and resources allocation of EMS is low, and the provision of such services has not met the needs of patients. To narrow the gap of equity, improvement in the capability of EMS to decrease cerebrovascular, cardiovascular, injury and poisoning cases, should be regarded as a top priority. In poor areas, allocation of facilities and human resources needs to be improved, and the economy should also be enhanced.

Quality of care in reproductive health programmes: education for quality improvement.

PubMed

Kwast, B E

1998-09-01

The provision of high quality maternity care will make the difference between life and death or lifelong maiming for millions of pregnant women. Barriers preventing access to affordable, appropriate, acceptable and effective services, and lack of facilities providing high quality obstetric care result in about 1600 maternal deaths every day. Education in its broadest sense is required at all levels and sectors of society to enhance policy formulation that will strengthen programme commitment, improve services with a culturally sensitive approach and ensure appropriate delegation of responsibility to health staff at peripheral levels. This paper is the second in series of three which addresses quality of care. The first (Kwast 1998) contains an overview of concepts, assessments, barriers and improvements of quality of care. The third article will describe selected aspects of monitoring and evaluation of quality of care.

Maternal residential proximity to nuclear facilities and low birth weight in offspring in Texas.

PubMed

Gong, Xi; Benjamin Zhan, F; Lin, Yan

2017-03-01

Health effects of close residential proximity to nuclear facilities have been a concern for both the general public and health professionals. Here, a study is reported examining the association between maternal residential proximity to nuclear facilities and low birth weight (LBW) in offspring using data from 1996 through 2008 in Texas, USA. A case-control study design was used together with a proximity-based model for exposure assessment. First, the LBW case/control births were categorized into multiple proximity groups based on distances between their maternal residences and nuclear facilities. Then, a binary logistic regression model was used to examine the association between maternal residential proximity to nuclear facilities and low birth weight in offspring. The odds ratios were adjusted for birth year, public health region of maternal residence, child's sex, gestational weeks, maternal age, education, and race/ethnicity. In addition, sensitivity analyses were conducted for the model. Compared with the reference group (more than 50 km from a nuclear facility), the exposed groups did not show a statistically significant increase in LBW risk [adjusted odds ratio (aOR) 0.91 (95% confidence interval (CI): 0.81, 1.03) for group 40-50 km; aOR 0.98 (CI 0.84, 1.13) for group 30-40 km; aOR 0.95 (CI 0.79, 1.15) for group 20-30 km; aOR 0.86 (CI 0.70, 1.04) for group 10-20 km; and aOR 0.98 (CI 0.59, 1.61) for group 0-10 km]. These results were also confirmed by results of the sensitivity analyses. The results suggest that maternal residential proximity to nuclear facilities is not a significant factor for LBW in offspring.

Health workers' perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia.

PubMed

Gebrehiwot, Tesfay; San Sebastian, Miguel; Edin, Kerstin; Goicolea, Isabel

2014-04-10

Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. Ethiopia is a major contributor to the worldwide death toll of mothers with a maternal mortality ratio of 676 per 100,000 live births. The Ethiopian Ministry of Health launched a community-based health-care system in 2003, the Health Extension Programme (HEP), to tackle maternal mortality. Despite strong efforts, universal access to services remains limited, particularly skilled delivery attendance. With the help of 'the three delays' framework, this study explores health-service providers' perceptions of facilitators and barriers to the utilization of institutional delivery in Tigray, a northern region of Ethiopia. Twelve in-depth interviews were carried out with eight health extension workers (HEWs) and four midwives. Each interview lasted between 90 and 120 minutes. Data were analysed through a thematic analysis approach. Three themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources. These themes represent the three steps in the path towards receiving adequate institutional delivery care at a health facility. Of the themes, 'increased community awareness', 'organization of the community' and 'hospital with specialized staff' were recognized as facilitators. On the other hand, 'delivery as a natural event', 'cultural tradition and rituals', 'inaccessible transport', 'unmet community expectation' and 'shortage of skilled human resources' were represented as barriers to institutional delivery. The participants in this study gave emphasis to the major barriers to institutional delivery that are closely connected with the three delays model. Despite the initiatives being implemented by the Tigray Regional Health Bureau, much is still needed to enhance the humanization approach of delivery care on a broader level of the region. A quick solution is needed to address the major issue of lack of transport accessibility. The poor capacity of the HEWs to provide delivery services, calls for reconsidering staffing patterns of remote health posts and readdressing the issue of downgraded health facilities would address unmet community needs.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

PubMed

Abalos, E; Cuesta, C; Carroli, G; Qureshi, Z; Widmer, M; Vogel, J P; Souza, J P

2014-03-01

To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions. Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database. Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East. All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period. We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model. Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes. Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions. The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Late Maternal Deaths and Deaths from Sequelae of Obstetric Causes in the Americas from 1999 to 2013: A Trend Analysis.

PubMed

de Cosio, Federico G; Jiwani, Safia S; Sanhueza, Antonio; Soliz, Patricia N; Becerra-Posada, Francisco; Espinal, Marcos A

2016-01-01

Data on maternal deaths occurring after the 42 days postpartum reference time is scarce; the objective of this analysis is to explore the trend and magnitude of late maternal deaths and deaths from sequelae of obstetric causes in the Americas between 1999 and 2013, and to recommend including these deaths in the monitoring of the Sustainable Development Goals (SDGs). Exploratory data analysis enabled analyzing the magnitude and trend of late maternal deaths and deaths from sequelae of obstetric causes for seven countries of the Americas: Argentina, Brazil, Canada, Colombia, Cuba, Mexico and the United States. A Poisson regression model was developed to compare trends of late maternal deaths and deaths from sequelae of obstetric causes between two periods of time: 1999 to 2005 and 2006 to 2013; and to estimate the relative increase of these deaths in the two periods of time. The proportion of late maternal deaths and deaths from sequelae of obstetric causes ranged between 2.40% (CI 0.85% - 5.48%) and 18.68% (CI 17.06% - 20.47%) in the seven countries. The ratio of late maternal deaths and deaths from sequelae of obstetric causes per 100,000 live births has increased by two times in the region of the Americas in the period 2006-2013 compared to the period 1999-2005. The regional relative increase of late maternal death was 2.46 (p<0.0001) times higher in the second period compared to the first. Ascertainment of late maternal deaths and deaths from sequelae of obstetric causes has improved in the Americas since the early 2000's due to improvements in the quality of information and the obstetric transition. Late and obstetric sequelae maternal deaths should be included in the monitoring of the SDGs as well as in the revision of the International Classification of Diseases' 11th version (ICD-11).

Late Maternal Deaths and Deaths from Sequelae of Obstetric Causes in the Americas from 1999 to 2013: A Trend Analysis

PubMed Central

de Cosio, Federico G.; Sanhueza, Antonio; Soliz, Patricia N.; Becerra-Posada, Francisco; Espinal, Marcos A.

2016-01-01

Background Data on maternal deaths occurring after the 42 days postpartum reference time is scarce; the objective of this analysis is to explore the trend and magnitude of late maternal deaths and deaths from sequelae of obstetric causes in the Americas between 1999 and 2013, and to recommend including these deaths in the monitoring of the Sustainable Development Goals (SDGs). Methods Exploratory data analysis enabled analyzing the magnitude and trend of late maternal deaths and deaths from sequelae of obstetric causes for seven countries of the Americas: Argentina, Brazil, Canada, Colombia, Cuba, Mexico and the United States. A Poisson regression model was developed to compare trends of late maternal deaths and deaths from sequelae of obstetric causes between two periods of time: 1999 to 2005 and 2006 to 2013; and to estimate the relative increase of these deaths in the two periods of time. Findings The proportion of late maternal deaths and deaths from sequelae of obstetric causes ranged between 2.40% (CI 0.85% – 5.48%) and 18.68% (CI 17.06% – 20.47%) in the seven countries. The ratio of late maternal deaths and deaths from sequelae of obstetric causes per 100,000 live births has increased by two times in the region of the Americas in the period 2006-2013 compared to the period 1999-2005. The regional relative increase of late maternal death was 2.46 (p<0.0001) times higher in the second period compared to the first. Interpretation Ascertainment of late maternal deaths and deaths from sequelae of obstetric causes has improved in the Americas since the early 2000’s due to improvements in the quality of information and the obstetric transition. Late and obstetric sequelae maternal deaths should be included in the monitoring of the SDGs as well as in the revision of the International Classification of Diseases’ 11th version (ICD-11). PMID:27626277

Using health-facility data to assess subnational coverage of maternal and child health indicators, Kenya.

PubMed

Maina, Isabella; Wanjala, Pepela; Soti, David; Kipruto, Hillary; Droti, Benson; Boerma, Ties

2017-10-01

To develop a systematic approach to obtain the best possible national and subnational statistics for maternal and child health coverage indicators from routine health-facility data. Our approach aimed to obtain improved numerators and denominators for calculating coverage at the subnational level from health-facility data. This involved assessing data quality and determining adjustment factors for incomplete reporting by facilities, then estimating local target populations based on interventions with near-universal coverage (first antenatal visit and first dose of pentavalent vaccine). We applied the method to Kenya at the county level, where routine electronic reporting by facilities is in place via the district health information software system. Reporting completeness for facility data were well above 80% in all 47 counties and the consistency of data over time was good. Coverage of the first dose of pentavalent vaccine, adjusted for facility reporting completeness, was used to obtain estimates of the county target populations for maternal and child health indicators. The country and national statistics for the four-year period 2012/13 to 2015/16 showed good consistency with results of the 2014 Kenya demographic and health survey. Our results indicated a stagnation of immunization coverage in almost all counties, a rapid increase of facility-based deliveries and caesarean sections and limited progress in antenatal care coverage. While surveys will continue to be necessary to provide population-based data, web-based information systems for health facility reporting provide an opportunity for more frequent, local monitoring of progress, in maternal and child health.

Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone.

PubMed

Sochas, Laura; Channon, Andrew Amos; Nam, Sara

2017-11-01

Although the number of direct Ebola-related deaths from the 2013 to 2016 West African Ebola outbreak has been quantified, the number of indirect deaths, resulting from decreased utilization of routine health services, remains unknown. Such information is a key ingredient of health system resilience, essential for adequate allocation of resources to both 'crisis response activities' and 'core functions'. Taking stock of indirect deaths may also help the concept of health system resilience achieve political traction over the traditional approach of disease-specific surveillance. This study responds to these imperatives by quantifying the extent of the drop in utilization of essential reproductive, maternal and neonatal health services in Sierra Leone during the Ebola outbreak by using interrupted time-series regression to analyse Health Management Information System (HMIS) data. Using the Lives Saved Tool, we then model the implication of this decrease in utilization in terms of excess maternal and neonatal deaths, as well as stillbirths. We find that antenatal care coverage suffered from the largest decrease in coverage as a result of the Ebola epidemic, with an estimated 22 percentage point (p.p.) decrease in population coverage compared with the most conservative counterfactual scenario. Use of family planning, facility delivery and post-natal care services also decreased but to a lesser extent (-6, -8 and -13 p.p. respectively). This decrease in utilization of life-saving health services translates to 3600 additional maternal, neonatal and stillbirth deaths in the year 2014-15 under the most conservative scenario. In other words, we estimate that the indirect mortality effects of a crisis in the context of a health system lacking resilience may be as important as the direct mortality effects of the crisis itself. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

[Maternal deaths due to infectious cause, results from the French confidential enquiry into maternal deaths, 2010-2012].

PubMed

Rigouzzo, A; Tessier, V; Zieleskiewicz, L

2017-12-01

Over the period 2010-2012, maternal mortality from infectious causes accounted for 5% of maternal deaths by direct causes and 16% of maternal deaths by indirect causes. Among the 22 deaths caused by infection occurred during this period, 6 deaths were attributed to direct causes from genital tract origin, confirming thus the decrease in direct maternal deaths by infection during the last ten years. On the contrary, indirect maternal deaths by infection, from extragenital origin, doubled during the same period, with 16 deaths in the last triennium, dominated by winter respiratory infections, particularly influenza: the 2009-2010 influenza A (H1N1) virus pandemic was the leading cause of indirect maternal mortality by infection during the studied period. The main infectious agents involved in maternal deaths from direct causes were Streptococcus A, Escherichia Coli and Clostridium perfringens: these bacterias were responsible for toxic shock syndrome, severe sepsis, secondary in some cases to cellulitis or necrotizing fasciitis. Of the 6 deaths due to direct infection, 4 were considered avoidable because of inadequate management: delayed or missed diagnosis, delayed or inadequate initiation of a specific medical and/or surgical treatment. Of the 16 indirect maternal deaths due to infection causes, the most often involved infectious agents were influenza A (H1N1) virus and Streptococcus pneumonia with induced purpura fulminans: the absence of influenza vaccination during pregnancy, delayed diagnosis and emergency initiation of a specific treatment, were the main contributory factors to these deaths and their avoidability in 70% of the cases analyzed. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Determinants of stillbirths in Ghana: does quality of antenatal care matter?

PubMed

Afulani, Patience A

2016-06-02

Each year, over two million babies die before they are born. Like maternal deaths, the great majority of these stillbirths occur in developing countries, with about a third of all cases worldwide in sub-Saharan Africa (SSA). Few studies have, however, examined the determinants of stillbirths in SSA. In addition, the emphases on promoting deliveries by skilled birth attendants and/or in health facilities to prevent maternal deaths, though important, may have undermined efforts to provide good quality antenatal care (ANC), which may have an additional role in preventing stillbirths. This study examines the factors associated with stillbirths in Ghana, focusing on the role of ANC quality. Data are from the Ghana Maternal Health Survey (N = 4,868)-a national survey of women of reproductive age. The main analysis includes women who had a pregnancy ending in a live birth or stillbirth in the five years preceding the survey and who received ANC at least once. ANC quality is measured by an index based on receipt (or otherwise) of nine antenatal services during the last pregnancy, including education about pregnancy complications; with receipt of at least of eight services classified as higher quality ANC. Stillbirths refer to babies born dead at seven or more months of pregnancy. Analytic techniques include multilevel logistic regression, with moderation and mediation analysis to examine conditional and intervening effects respectively. Higher quality ANC decreases the odds of a stillbirth by almost half after accounting for other factors, including the type of delivery provider and facility. Educating pregnant women about pregnancy complications contributes significantly to this difference by ANC quality. The type of delivery facility and provider account for a small proportion (14 %) of the ANC quality effect on stillbirths and a larger proportion of the rural/urban difference (27 %) in stillbirths. Completing the recommended four antenatal visits decreases the odds of a stillbirth. Having a pregnancy complication, a multiple gestation, a past stillbirth, or a sister who died from pregnancy complications increases the odds of a stillbirth. Good quality ANC can improve birth outcomes in two ways: directly through preventative measures, and indirectly through promoting deliveries in health facilities where complications can be better managed. Targeted programs and policies to increase ANC quality, including adequately educating women on pregnancy complications, will help improve birth outcomes in Ghana, and in SSA as a whole.

Using human rights in maternal mortality programs: from analysis to strategy.

PubMed

Freedman, L P

2001-10-01

This article describes an approach to maternal mortality reduction that uses human rights not simply to denounce the injustice of death in pregnancy and childbirth, but also to guide the design and implementation of maternal mortality policies and programs. As a first principle, programs and policies need to prioritize measures that promote universal access to high quality emergency obstetric care services, which we know from health research are essential to saving women's lives. With that priority, human rights principles can be integrated into programs at the clinical, facility management, and national policy levels. For example, a human rights 'audit' can help identify ways to encourage respectful, non-discriminatory treatment of patients, providers and staff in the clinical setting. Human rights principles of entitlement and accountability can inform mechanisms of community participation designed to improve responsiveness and functioning of health facilities. Human rights principles can inform analysis of health sector reform and its impact on access to emergency obstetric care. Whether applied to the intricacies of human relationships within a facility or to the impact of international financial institutions on health systems, the ultimate role of human rights is to identify the workings of power that keep unacceptable levels of maternal morality as they are and to use the human rights vision of dignity and social justice to work for the re-arrangements of power necessary for change.

[Maternal mortality rate in the Aurelio Valdivieso General Hospital: a ten years follow up].

PubMed

Noguera-Sánchez, Marcelo Fidias; Arenas-Gómez, Susana; Rabadán-Martínez, Cesar Esli; Antonio-Sánchez, Pedro

2013-01-01

In México, the maternal mortality rate has been diminishing in the country in the last decades, except in the state of Oaxaca. Oaxaca is located amongst the entities with the highest ratios of maternal mortality. To analyze the behavior and epidemiological tendencies of maternal mortality over 10 years at the Dr. Aurelio Valdivieso General Hospital. In a retrospective, descriptive, and transverse analysis, we reviewed the maternal mortality files from the gynecology and obstetrics division. Three sets of variables were designed: social, obstetrical and circumstantial. We used general and descriptive statistical tools. From January first to December 31th of 2009 there were registered 109 maternal deaths. Excluding 2 non-obstetrical deaths, ths results in 107 maternal deaths. Divided into 75 direct maternal deaths and 32 indirect maternal deaths, the maternal mortality rate was 172.14 × 100,000 livebirths. Eighty-nine maternal deaths were foreseeable (83%) and 18 were not foreseeable (17%) as was stated by the Ad Hoc Committee within the Dr. Aurelio Valdivieso General Hospital. Pregnancy-related hypertension accounts for the highest pathology in relation to maternal deaths, the low literacy and puerperium correlated to a higher risk. Low human development index and low literacy were the variables that accounted for higher mortality risk. Also, we found that the higher occurrence of maternal deaths appeared during the puerperium and within hospital wards. The maternal mortality rate founded was the higher amongst the various areas of the country.

Causes of maternal and child mortality among Cambodian sex workers and their children: a cross sectional study.

PubMed

Willis, Brian; Onda, Saki; Stoklosa, Hanni Marie

2016-11-21

To reach global and national goals for maternal and child mortality, countries must identify vulnerable populations, which includes sex workers and their children. The objective of this study was to identify and describe maternal deaths of female sex workers in Cambodia and causes of death among their children. A convenience sample of female sex workers were recruited by local NGOs that provide support to sex workers. We modified the maternal mortality section of the 2010 Cambodia Demographic and Health Survey and collected reports of all deaths of female sex workers. For each death we ask the 'sisterhood' methodology questions to identify maternal deaths. For child deaths we asked each mother who reported the death of a child about the cause of death. We also asked all participants about the cause of deaths of children of other female sex workers. We interviewed 271 female sex workers in the four largest Cambodian cities between May and September 2013. Participants reported 32 deaths of other female sex workers that met criteria for maternal death. The most common reported causes of maternal deaths were abortion (n = 13;40%) and HIV (n = 5;16%). Participants report deaths of 8 of their children and 50 deaths of children of other female sex workers. HIV was the reported cause of death for 13 (36%) children under age five. This is the first report of maternal deaths of sex workers in Cambodia or any other country. This modification of the sisterhood methodology has not been validated and did not allow us to calculate maternal mortality rates so the results are not generalizable, however these deaths may represent unrecognized maternal deaths in Cambodia. The results also indicate that children of sex workers in Cambodia are at risk of HIV and may not be accessing treatment. These issues require additional studies but in the meantime we must assure that sex workers in Cambodia and their children have access to quality health services.

Space-time patterns in maternal and mother mortality in a rural South African population with high HIV prevalence (2000-2014): results from a population-based cohort.

PubMed

Tlou, B; Sartorius, B; Tanser, F

2017-06-03

International organs such as, the African Union and the South African Government view maternal health as a dominant health prerogative. Even though most countries are making progress, maternal mortality in South Africa (SA) significantly increased between 1990 and 2015, and prevented the country from achieving Millennium Development Goal 5. Elucidating the space-time patterns and risk factors of maternal mortality in a rural South African population could help target limited resources and policy guidelines to high-risk areas for the greatest impact, as more generalized interventions are costly and often less effective. Population-based mortality data from 2000 to 2014 for women aged 15-49 years from the Africa Centre Demographic Information System located in the Umkhanyakude district of KwaZulu-Natal Province, South Africa were analysed. Our outcome was classified into two definitions: Maternal mortality; the death of a woman while pregnant or within 42 days of cessation of pregnancy, regardless of the duration and site of the pregnancy, from any cause related to or exacerbated by the pregnancy or its management but not from unexpected or incidental causes; and 'Mother death'; death of a mother whilst child is less than 5 years of age. Both the Kulldorff and Tango spatial scan statistics for regular and irregular shaped cluster detection respectively were used to identify clusters of maternal mortality events in both space and time. The overall maternal mortality ratio was 650 per 100,000 live births, and 1204 mothers died while their child was less than or equal to 5 years of age, of a mortality rate of 370 per 100,000 children. Maternal mortality declined over the study period from approximately 600 per 100,000 live births in 2000 to 400 per 100,000 live births in 2014. There was no strong evidence of spatial clustering for maternal mortality in this rural population. However, the study identified a significant spatial cluster of mother deaths in childhood (p = 0.022) in a peri-urban community near the national road. Based on our multivariable logistic regression model, HIV positive status (Adjusted odds ratio [aOR] = 2.5, CI 95%: [1.5-4.2]; primary education or less (aOR = 1.97, CI 95%: [1.04-3.74]) and parity (aOR = 1.42, CI 95%: [1.24-1.63]) were significant predictors of maternal mortality. There has been an overall decrease in maternal and mother death between 2000 and 2014. The identification of a clear cluster of mother deaths shows the possibility of targeting intervention programs in vulnerable communities, as population-wide interventions may be ineffective and too costly to implement.

Performance Based Financing and Uptake of Maternal and Child Health Services in Yobe Sate, Northern Nigeria

PubMed Central

Ashir, Garba M.; Doctor, Henry V.; Afenyadu, Godwin Y.

2013-01-01

Reported maternal and child health (MCH) outcomes in Nigeria are amongst the worst in the world, with Nigeria second only to India in the number of maternal deaths. At the national level, maternal mortality ratios (MMRs) are estimated at 630 deaths per 100,000 live births (LBs) but vary from as low as 370 deaths per 100,000 LBs in the southern states to over 1,000 deaths per 100,000 LBs in the northern states. We report findings from a performance based financing (PBF) pilot study in Yobe State, northern Nigeria aimed at improving MCH outcomes as part of efforts to find strategies aimed at accelerating attainment of Millennium Development Goals for MCH. Results show that the demand-side PBF led to increased utilization of key MCH services (antenatal care and skilled delivery) but had no significant effect on completion of child immunization using measles as a proxy indicator. We discuss these results within the context of PBF schemes and the need for a careful consideration of all the critical processes and risks associated with demand-side PBF schemes in improving MCH outcomes in the study area and similar settings. PMID:23618473

Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa.

PubMed

Maswime, T S; Buchmann, E

2017-10-31

A rising caesarean section rate and substandard peri-operative care are believed to be the main reasons for recent increases in maternal deaths from bleeding during and after caesarean section (BDACS) in South Africa (SA). The Donabedian model assumes that clinical outcomes are influenced by healthcare workers and the healthcare system. To evaluate near-miss cases from BDACS with regard to health system structure (resources and facilities) and process (patient care). A cross-sectional prospective study was conducted in greater Johannesburg, SA. Data of women who had near-miss-related BDACS were collected by means of ongoing surveillance at 13 public hospitals. The World Health Organization intervention criteria were used to identify near-miss cases. A comparison of structure and process between the healthcare facilities was conducted. Of 20 527 caesarean sections , there were 93 near misses and 7 maternal deaths from BDACS. Dominant risk factors for near misses were previous caesarean section (43.9%), anaemia (25.3%) and pregnancy-induced hypertension (28.6%). Eighteen women were transferred to higher levels of care, and 8 (44.4%) experienced transport delays of >1 hour. The caesarean section decision-to-incision interval (DII) was ≥60 minutes in 77 of 86 women, with an average interval of 4 hours. Structural deficiencies were frequently present in district hospitals, and there were serious delays in ambulance transfer and DIIs at all levels of care. The majority of the women had risk factors for BDACS. There were major ambulance delays and lack of facilities, mostly in district hospitals. All women required life-saving interventions, but could not access appropriate care timeously. Prevention and management of BDACS require a fully functional health system.

Can the right to health inform public health planning in developing countries? A case study for maternal healthcare from Indonesia.

PubMed

D'Ambruoso, Lucia; Byass, Peter; Nurul Qomariyah, Siti

2008-09-09

Maternal mortality remains unacceptably high in developing countries despite international advocacy, development targets, and simple, affordable and effective interventions. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged. We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal healthcare. Our objective was to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective. Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceased's relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death. In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld. The rights-based approach could identify how and where to improve services. However, there are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning.

Misclassified maternal deaths among East African immigrants in Sweden.

PubMed

Elebro, Karin; Rööst, Mattias; Moussa, Kontie; Johnsdotter, Sara; Essén, Birgitta

2007-11-01

Western countries have reported an increased risk of maternal mortality among African immigrants. This study aimed to identify cases of maternal mortality among immigrants from the Horn of Africa living in Sweden using snowball sampling, and verify whether they had been classified as maternal deaths in the Cause of Death Registry. Three "locators" contacted immigrants from Somalia, Eritrea, and Ethiopia to identify possible cases of maternal mortality. Suspected deaths were scrutinised through verbal autopsy and medical records. Confirmed instances, linked by country of birth, were compared with Registry statistics. We identified seven possible maternal deaths of which four were confirmed in medical records, yet only one case had been classified as such in the Cause of Death Registry. At least two cases, a significant number, seemed to be misclassified. The challenges of both cultural and medical competence for European midwives and obstetricians caring for non-European immigrant mothers should be given more attention, and the chain of information regarding maternal deaths should be strengthened. We propose a practice similar to the British confidential enquiry into maternal deaths. In Sweden, snowball sampling was valuable for contacting immigrant communities for research on maternal mortality; by strengthening statistical validity, it can contribute to better maternal health policy in a multi-ethnic society.

Maternal death from stroke: a thirty year national retrospective review.

PubMed

Foo, Lin; Bewley, Susan; Rudd, Anthony

2013-12-01

In the United Kingdom (UK), the maternal mortality rate from stroke is reported at 0.3/100,000 deliveries, but only antenatal data have previously been reviewed. We hypothesise that the true rate is much higher due to a propensity for stroke occurring in the post-partum period, and that the rate will rise in parallel with trends of increasing maternal age and medical co-morbidities. Our objectives are to investigate the UK stroke mortality rate in pregnancy and the puerperium, and to examine temporal changes in fatal maternal strokes over a 30 year period. Retrospective review of stroke-related maternal deaths reported to the UK confidential enquiries into maternal death between 1979 and 2008, encompassing 21,514,457 maternities. In accordance with the ICD.10 classification, cases were divided into direct or indirect deaths. Late and coincidental deaths were not included in analyses. Lessons from sub-standard care associated with maternal death from stroke were collated. In 1979-2008 there were 347 maternal deaths from stroke: 139 cases were direct deaths, i.e. the fatal stroke was a direct result of pregnancy. The incidence of fatal stroke is relatively constant at 1.61/100,000 maternities, with a 13.9% (95% CI 12.6-15.3) proportional mortality rate. Intracranial haemorrhage was the single greatest cause of maternal death from stroke. This is the largest UK study examining the incidence of fatal maternal stroke in pregnancy and the puerperium. Our results highlight the high proportion of women who die from stroke in the puerperium. Sub-standard care featured especially in regard to management of dangerously high systolic blood pressure levels. These deaths highlight the importance of education in managing rapid-onset hypertension and superimposed coagulopathies. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes.

PubMed

Lassi, Zohra S; Haider, Batool A; Bhutta, Zulfiqar A

2010-11-10

While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. We searched The Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010), World Bank's JOLIS (12 January 2010), BLDS at IDS and IDEAS database of unpublished working papers (12 January 2010), Google and Google Scholar (12 January 2010). All prospective randomised and quasi-experimental trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities; and improving neonatal outcomes. Two review authors independently assessed trial quality and extracted the data. The review included 18 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from one trial. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio estimates were used along with the standard error of the logarithms of risk ratio estimates. Our review did not show any reduction in maternal mortality (risk ratio (RR) 0.77; 95% confidence interval (CI) 0.59 to 1.02, random-effects (10 studies, n = 144,956), I² 39%, P value 0.10. However, significant reduction was observed in maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92, random-effects (four studies, n = 138,290), I² 28%; neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84, random-effects (12 studies, n = 136,425), I² 69%, P value < 0.001), stillbirths (RR 0.84; 95% CI 0.74 to 0.97, random-effects (11studies, n = 113,821), I² 66%, P value 0.001) and perinatal mortality (RR 0.80; 95% CI 0.71 to 0.91, random-effects (10 studies, n = 110,291), I² 82%, P value < 0.001) as a consequence of implementation of community-based interventional care packages. It also increased the referrals to health facility for pregnancy related complication by 40% (RR 1.40; 95% CI 1.19 to 1.65, fixed-effect (two studies, n = 22,800), I² 0%, P value 0.76), and improved the rates of early breastfeeding by 94% (RR 1.94; 95% CI 1.56 to 2.42, random-effects (six studies, n = 20,627), I² 97%, P value < 0.001). We assessed our primary outcomes for publication bias, but observed no such asymmetry on the funnel plot. Our review offers encouraging evidence of the value of integrating maternal and newborn care in community settings through a range of interventions which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

PubMed

Mahato, Preeti K; Waithaka, Elizabeth; van Teijlingen, Edwin; Pant, Puspa Raj; Biswas, Animesh

2018-04-01

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Factors Underlying the Temporal Increase in Maternal Mortality in the United States

PubMed Central

Joseph, K.S.; Lisonkova, Sarka; Muraca, Giulia M.; Razaz, Neda; Sabr, Yasser; Mehrabadi, Azar; Schisterman, Enrique F.

2016-01-01

OBJECTIVE To identify the factors underlying the recent increase in maternal mortality ratios (maternal deaths per 100,000 live births) in the United States. METHODS We carried out a retrospective study with data on maternal deaths and live births in the United States from 1993 to 2014 obtained from the birth and death files of the Centers for Disease Control and Prevention. Underlying causes of death were examined between 1999 and 2014 using International Classification of Diseases, Tenth Revision (ICD-10) codes. Poisson regression was used to estimate maternal mortality rate ratios (RR) and 95% confidence intervals (CI) after adjusting for the introduction of a separate pregnancy question and the standard pregnancy checkbox on death certificates, and adoption of ICD-10. RESULTS Maternal mortality ratios increased from 7.55 in 1993, to 9.88 in 1999 and to 21.5 per 100,000 live births in 2014 (RR 2014 vs 1993 2.84, 95% CI 2.49 to 3.24; RR 2014 vs 1999 2.17, 95% CI 1.93 to 2.45). The increase in maternal deaths from 1999 to 2014 was mainly due to increases in maternal deaths associated with two new ICD-10 codes (O26.8 i.e., primarily renal disease and O99 i.e., other maternal diseases classifiable elsewhere); exclusion of such deaths abolished the increase in mortality (RR 1.09, 95% CI 0.94 to 1.27). Regression adjustment for improvements in surveillance also abolished the temporal increase in maternal mortality ratios (adjusted maternal mortality ratios 7.55 in 1993, 8.00 per 100,000 live births in 2013; adjusted RR 2013 vs 1993 1.06, 95% CI 0.90 to 1.25). CONCLUSION Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death. Complete ascertainment of maternal death in populations remains a challenge even in countries with good systems for civil registration and vital statistics. PMID:27926651

Spatial autocorrelation in uptake of antenatal care and relationship to individual, household and village-level factors: results from a community-based survey of pregnant women in six districts in western Kenya.

PubMed

Prudhomme O'Meara, Wendy; Platt, Alyssa; Naanyu, Violet; Cole, Donald; Ndege, Samson

2013-12-07

The majority of maternal deaths, stillbirths, and neonatal deaths are concentrated in a few countries, many of which have weak health systems, poor access to health services, and low coverage of key health interventions. Early and consistent antenatal care (ANC) attendance could significantly reduce maternal and neonatal morbidity and mortality. Despite this, most Kenyan mothers initiate ANC care late in pregnancy and attend fewer than the recommended visits. We used survey data from 6,200 pregnant women across six districts in western Kenya to understand demand-side factors related to use of ANC. Bayesian multi-level models were developed to explore the relative importance of individual, household and village-level factors in relation to ANC use. There is significant spatial autocorrelation of ANC attendance in three of the six districts and considerable heterogeneity in factors related to ANC use between districts. Working outside the home limited ANC attendance. Maternal age, the number of small children in the household, and ownership of livestock were important in some districts, but not all. Village proportions of pregnancy in women of child-bearing age was significantly correlated to ANC use in three of the six districts. Geographic distance to health facilities and the type of nearest facility was not correlated with ANC use. After incorporating individual, household and village-level covariates, no residual spatial autocorrelation remained in the outcome. ANC attendance was consistently low across all the districts, but factors related to poor attendance varied. This heterogeneity is expected for an outcome that is highly influenced by socio-cultural values and local context. Interventions to improve use of ANC must be tailored to local context and should include explicit approaches to reach women who work outside the home.

Validating the WHO Maternal Near Miss Tool in a high-income country.

PubMed

Witteveen, Tom; de Koning, Ilona; Bezstarosti, Hans; van den Akker, Thomas; van Roosmalen, Jos; Bloemenkamp, Kitty W

2016-01-01

This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high-income country. The MNM tool was applied to 2552 women who died of pregnancy-related causes or sustained severe acute maternal morbidity between August 2004 and August 2006 in one of the 98 hospitals with a maternity unit in the Netherlands. Fourteen (0.6%) cases had insufficient data for application. Each case was assessed according to the three main "MNM categories" specified in the MNM tool and their subcategory criteria: five disease-, four intervention- and seven organ dysfunction-based criteria. Potentially life-threatening conditions (disease-based inclusions) and life-threatening cases (organ dysfunction-based inclusions) were differentiated according to WHO methodology. Outcomes were incidence of all (sub)categories and case-fatality rates. Of the 2538 cases, 2308 (90.9%) women fulfilled disease-based, 2116 (83.4%) intervention-based and 1024 (40.3%) organ dysfunction-based criteria. Maternal death occurred in 48 women, of whom 23 (47.9%) fulfilled disease-based, 33 (68.8%) intervention-based and 31 (64.6%) organ dysfunction-based criteria. Case-fatality rates were 23/2308 (1.0%) for cases fulfilling the disease-based criteria, 33/2116 (1.6%) for intervention-based criteria and 31/1024 (3.0%) for women fulfilling the organ dysfunction-based criteria. In the Netherlands, where advanced laboratory and clinical monitoring are available, organ dysfunction-based criteria of the MNM tool failed to identify nearly two-thirds of sustained severe acute maternal morbidity cases and more than one-third of maternal deaths. Disease-based criteria remain important, and using only organ dysfunction-based criteria would lead to underestimating severe acute maternal morbidity. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Stillbirths: rates, risk factors, and acceleration towards 2030.

PubMed

Lawn, Joy E; Blencowe, Hannah; Waiswa, Peter; Amouzou, Agbessi; Mathers, Colin; Hogan, Dan; Flenady, Vicki; Frøen, J Frederik; Qureshi, Zeshan U; Calderwood, Claire; Shiekh, Suhail; Jassir, Fiorella Bianchi; You, Danzhen; McClure, Elizabeth M; Mathai, Matthews; Cousens, Simon

2016-02-06

An estimated 2.6 million third trimester stillbirths occurred in 2015 (uncertainty range 2.4-3.0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1.3 million (uncertainty range 1.2-1.6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8.0% and syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6.7%). Prolonged pregnancies contribute to 14.0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth. Copyright © 2016 Elsevier Ltd. All rights reserved.

Aortic dissection in pregnancy in England: an incidence study using linked national databases

PubMed Central

Banerjee, Amitava; Begaj, Irena; Thorne, Sara

2015-01-01

Objectives To conduct the first population-level incidence study of aortic dissection in pregnancy using linked hospital-based data in England. Setting Hospital-based data (Hospital Episode Statistics (HES) linked with mortality data from the Office of National Statistics), national enquiries (Confidential Enquiries into Maternal Mortality) and surveys (UK Obstetric Surveillance System; UKOSS) of aortic dissection in pregnancy from 2003 to 2011 in England. Participants Between 2003 and 2011, all female patients admitted with diagnoses of aortic dissection (not necessarily as the primary cause of admission) and of pregnancy, childbirth and puerperium, were included. Outcome measures Diagnosis of aortic dissection during pregnancy, operated or not operated, with outcome of death or live patient from 2003 to 2011 in England. Results There were significant differences in characteristics of databases with respect to study population, time of study, recorded event and follow-up of outcomes. On the basis of HES, annual incidence of aortic dissection was 1.23 (95% CI 1.22 to 1.24) per 100 000 maternities. Incidence of aortic dissection with death within 1 year was 0.30 (0.29 to 0.31) per 100 000 maternities. Incidence of aortic dissection increased from 0.74 (0.73 to 0.75) per 100 000 maternities in 2003–2005 to 1.52 (1.51 to 1.53) per 100 000 maternities in 2009–2011. In the Confidential Enquiries into Maternal Deaths, incidence of deaths was highest for 2003–2005 (0.43/100 000 maternities) and lowest for 1997–1999 (0.21/100 000 maternities). In the UK Obstetric Surveillance System, national incidence of aortic dissection was 0.80 (0.50 to 1.50) per 100 000 maternities between 2009 and 2011. Conclusions The case of aortic dissection in pregnancy illustrates data limitations regarding complications in pregnancy from different sources in the UK, even for a diagnosis with seemingly few alternative coding and diagnostic possibilities. These limitations should be acknowledged when estimating incidence and outcome. PMID:26297370

Utilization of healthcare services in postpartum women in the Philippines who delivered at home and the effects on their health: a cross-sectional analytical study.

PubMed

Yamashita, Tadashi; Reyes Tuliao, Maria Teresa; Concel Meana, Magdalena; Suplido, Sherri Ann; Llave, Cecilia L; Tanaka, Yuko; Matsuo, Hiroya

2017-01-01

A low ratio of utilization of healthcare services in postpartum women may contribute to maternal deaths during the postpartum period. The maternal mortality ratio is high in the Philippines. The aim of this study was to examine the current utilization of healthcare services and the effects on the health of women in the Philippines who delivered at home. This was a cross-sectional analytical study, based on a self-administrated questionnaire, conducted from March 2015 to February 2016 in Muntinlupa, Philippines. Sixty-three postpartum women who delivered at home or at a facility were enrolled for this study. A questionnaire containing questions regarding characteristics, utilization of healthcare services, and abnormal symptoms during postpartum period was administered. To analyze the questionnaire data, the sample was divided into delivery at home and delivery at a facility. Chi-square test, Fisher's exact test, and Mann-Whitney U test were used. There were significant differences in the type of birth attendant, area of residence, monthly income, and maternal and child health book usage between women who delivered at home and those who delivered at a facility ( P <0.01). There was significant difference in the utilization of antenatal checkup ( P <0.01) during pregnancy, whilst there was no significant difference in utilization of healthcare services during the postpartum period. Women who delivered at home were more likely to experience feeling of irritated eyes and headaches, and continuous abdominal pain ( P <0.05). Financial and environmental barriers might hinder the utilization of healthcare services by women who deliver at home in the Philippines. Low utilization of healthcare services in women who deliver at home might result in more frequent abnormal symptoms during postpartum.

Maternal and pregnancy-related death: causes and frequencies in an autopsy study population.

PubMed

Buschmann, Claas; Schmidbauer, Martina; Tsokos, Michael

2013-09-01

Maternal deaths during pregnancy, both from pregnancy-related or other causes, are rare in Western industrialized countries. In this study we report maternal and pregnancy-related deaths in a large autopsy population focusing on medical history, autopsy findings and histological examinations. Medico-legal autopsy files (n = 11,270) from the Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charité, University of Berlin, and the State Institute of Legal and Social Medicine, Berlin, from 2005 to 2010 were reviewed. All female cases between 15 and 49 years were checked for maternal and pregnancy-related death, and deaths of pregnant women from non-natural causes were also included. Fatalities that met the chosen criteria were classified as "direct gestational death," "indirect gestational death" or "non-gestational death." 13 female fatalities (0.12 %) met the chosen criteria (median age 28 years ± 6.87 SD). Eight (61.5 %) women died in-hospital, four (30.8 %) at home, and one woman died in public. Three cases (23.1 %) were "non-gestational deaths," and one case (7.7 %) remained unclear after autopsy and additional examinations. Of the remaining nine cases, six cases (46.5 %) were "direct gestational deaths," and two cases (15.4 %) were "indirect gestational deaths." One case (7.7 %) was not to be defined as "late maternal death," but the cause of death seemed to be directly related to previous gestation ["(very) late maternal death"]. Maternal deaths during pregnancy, both from pregnancy-related or other causes, remain an uncommon event in routine forensic autopsy practice. We report on the collection and analysis of maternal and pregnancy-related deaths in a large autopsy population, with particular attention to the phenomenology of pregnancy, pathophysiological changes in different organ systems and their detection, and the forensic autopsy assessment.

The immediate economic impact of maternal deaths on rural Chinese households.

PubMed

Ye, Fang; Wang, Haijun; Huntington, Dale; Zhou, Hong; Li, Yan; You, Fengzhi; Li, Jinhua; Cui, Wenlong; Yao, Meiling; Wang, Yan

2012-01-01

To identify the immediate economic impact of maternal death on rural Chinese households. Results are reported from a study that matched 195 households who had suffered a maternal death to 384 households that experienced a childbirth without maternal death in rural areas of three provinces in China, using quantitative questionnaire to compare differences of direct and indirect costs between two groups. The direct costs of a maternal death were significantly higher than the costs of a childbirth without a maternal death (US$4,119 vs. $370, p<0.001). More than 40% of the direct costs were attributed to funeral expenses. Hospitalization and emergency care expenses were the largest proportion of non-funeral direct costs and were higher in households with maternal death than the comparison group (US$2,248 vs. $305, p<0.001). To cover most of the high direct costs, 44.1% of affected households utilized compensation from hospitals, and the rest affected households (55.9%) utilized borrowing money or taking loans as major source of money to offset direct costs. The median economic burden of the direct (and non-reimbursed) costs of a maternal death was quite high--37.0% of the household's annual income, which was approximately 4 times as high as the threshold for an expense being considered catastrophic. The immediate direct costs of maternal deaths are extremely catastrophic for the rural Chinese households in three provinces studied.

Maternal Mortality In Pakistan: Is There Any Metamorphosis Towards Betterment?

PubMed

Nisar, Nusrat; Abbasi, Razia Mustafa; Chana, Shehla Raza; Rizwan, Noushaba; Badar, Razia

2017-01-01

Every year more than half million mother die due to pregnancy related preventable causes like haemorrhage, hypertensive disorders, sepsis, and obstructed labour and unsafe abortion. Among these deaths 99% occur in developing countries. The study was conducted to assess the maternal death rate and to analyse its trends over a period of 20 years in tertiary care hospital in Sindh Province Pakistan. A retrospective analysis of maternal mortality records were carried out for a period of 20 years from 1986-1995 and 2011-2015 at the Department of Obstetrics and gynaecology Liaquat University of Medical and Health Sciences Hyderabad Sindh Pakistan. The record retrieved was categorized into four 5 yearly periods 1986- 1990, 1991-995, 2006-2010 and 2011-2015 for comparison of trends. The cumulative maternal mortality ratio (MMR) was 1521.5 per 100,000 live births. The comparison of first 5 years' period (1986-1990) and last 5 years (2011-2015) showed downward trend in maternal mortality rate from 2368.6-1265.1. Direct causes of death have accounted for 2820 (84.78%) of total maternal death. Sepsis was the major cause of death for first 5 years accounted for 196(35.1%) of maternal death while in the last 5 years' eclampsia causes 284 (27.84%) of direct maternal deaths. The reduction in the maternal deaths has been very slow. The direct causes were still the main reasons for obstetrical deaths.

How decision for seeking maternal care is made--a qualitative study in two rural medical districts of Burkina Faso.

PubMed

Somé, Donmozoun Télesphore; Sombié, Issiaka; Meda, Nicolas

2013-02-07

Delay in decision-making to use skilled care during pregnancy and childbirth is an important factor for maternal death in many developing countries. This paper examines how decisions for maternal care are made in two rural communities in Burkina Faso. Focus group discussions (FGDs) and individual interviews (IDIs)) were used to collect information with 30 women in Ouargaye and Diapaga medical districts. All interviews were tape recorded and analyzed using QSR Nvivo 2.0. Decision-making for use of obstetric care in the family follows the logic of the family's management. Husbands, brothers-in-law and parents-in-law make the decision about whether to use a health facility for antenatal care or for delivery. In general, decision-makers are those who can pay, including the woman herself. Payment of care is the responsibility of men, according to women interviewed, because of their social role and status. To increase use of health facilities in Ouargaye and Diapaga, the empowerment of women could be helpful as well as exemption of fees or cost sharing for care.

Can cash transfers improve determinants of maternal mortality? Evidence from the household and community programs in Indonesia.

PubMed

Kusuma, Dian; Cohen, Jessica; McConnell, Margaret; Berman, Peter

2016-08-01

Despite global efforts in maternal health, 303,000 maternal deaths still occurred globally in 2015. One explanation is a considerable inequality in maternal mortality and the sources such as nutritional status and health utilization. One strategy to fight health inequality due to poverty is conditional cash transfer (CCT). Taking advantage of two large clustered-randomized trials in Indonesia from 2007 to 2009, this paper provides evidence on the effects of household cash transfers (PKH) and community cash transfers (Generasi) on determinants of maternal mortality. The sample sizes are 14,000 households for PKH and 12,000 households for Generasi. After two years of implementation, difference-in-differences (DID) analyses show that the two programs can improve determinants of maternal mortality with Generasi provides positive impact in some aspects of determinants, but PKH does not. Generasi improves maternal health knowledge, reduces financial barriers to accessing health services and improves utilization of health services, increases utilization among higher-risk women, improves posyandu equipment, and increases nutritional intake. As for PKH, evidence shows its strongest effects only on utilization of health services. Both programs, however, are unlikely to have a large effect on maternal mortality due to design and implementation issues that might significantly reduce program effectiveness. While the programs improved utilization, they did so at community-based facilities not equipped with emergency obstetric care. In the midst of popularity of household cash transfer, our results show that community cash transfer offers a viable policy alternative to improve the determinants of maternal mortality by allowing more flexibility in activities and at lower cost by monitoring at community level. Copyright © 2016 Elsevier Ltd. All rights reserved.

Setting priorities for safe motherhood interventions in resource-scarce settings.

PubMed

Prata, Ndola; Sreenivas, Amita; Greig, Fiona; Walsh, Julia; Potts, Malcolm

2010-01-01

Guide policy-makers in prioritizing safe motherhood interventions. Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models. The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph). The combination of interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk. Those which save the most number of lives in each model are 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for LOW; 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for MED; and 'fpsa, anc-miso, sepsis, eclampsia treatment, safe delivery' for HIGH settings. Safe motherhood interventions save a significant number of newborn lives.

Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria.

PubMed

Wall, L L

1998-12-01

Northern Nigeria has a maternal mortality ratio greater than 1,000 maternal deaths per 100,000 live births. Serious maternal morbidity (for example, vesico-vaginal fistula) is also common. Among the most important factors contributing to this tragic situation are: an Islamic culture that undervalues women; a perceived social need for women's reproductive capacities to be under strict male control; the practice of purdah (wife seclusion), which restricts women's access to medical care; almost universal female illiteracy; marriage at an early age and pregnancy often occurring before maternal pelvic growth is complete; a high rate of obstructed labor; directly harmful traditional medical beliefs and practices; inadequate facilities to deal with obstetric emergencies; a deteriorating economy; and a political culture marked by rampant corruption and inefficiency. The convergence of all of these factors has resulted in one of the worst records of female reproductive health existing anywhere in the world.

Delivery of a very low birth weight infant and increased maternal risk of cancer and death: a population study with 16 years of follow-up.

PubMed

Grisaru-Granovsky, Sorina; Gordon, Ethel Sherry; Haklai, Ziona; Schimmel, Michael S; Drukker, Lior; Samueloff, Arnon; Keinan-Boker, Lital

2015-11-01

Pregnancy complications represent sentinel events for women's future health. We investigated whether delivery of a very low birth weight (VLBW) infant is associated with increased maternal risk for future incidence of maternal cancer and death. This is a population-based cohort study of linked Israeli Ministry of Health datasets between 1995 and 2011. Women delivering a live singleton <1,500 g infant (VLBW group) were compared with women delivering a live singleton, 3,000-3,500 g (control). The first pregnancy eligible for entry into the study, the "index pregnancy," reflected exposure status for each participant. Primary outcomes were maternal cancer and death. Cancer diagnoses were further classified by primary site. Cox regression models adjusted for follow-up period and maternal characteristics at index pregnancy: Age at delivery, ethnicity, years of education, marital status, and previous cancer afforded calculation of hazard ratios (HR) and 95% confidence intervals (CI). During the study period, 982,091 mothers with 2,243,736 live births were identified; of these, 13,773 births were VLBW eligible for inclusion in the study and 448,743 births were controls. Groups differed significantly by average follow-up and all maternal characteristics evaluated. Overall rate of cancers and death was significantly increased for VLBW women compared to controls: 18.4 versus 15.7% and 7.3 versus 3.2%, both p < 0.0001. The Cox model adjusted for maternal characteristics showed significantly increased risk of cancer (all sites) in the VLBW women: HR 1.18 (95% CI 1.02-1.37) and for death: HR 2.13 (95% CI 1.68-2.71), and an increased combined risk of both outcomes: HR 1.4 (95% CI 1.23-1.59). The delivery of a VLBW newborn is an independent lifetime risk factor for subsequent maternal cancers and death. These women may benefit from targeted cancer screening and counseling.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

PubMed

Hogan, Margaret C; Saavedra-Avendano, Biani; Darney, Blair G; Torres-Palacios, Luis M; Rhenals-Osorio, Ana L; Sierra, Bertha L Vázquez; Soliz-Sánchez, Patricia N; Gakidou, Emmanuela; Lozano, Rafael

2016-05-01

To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. We conducted a repeated cross-sectional study using the 2006-2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study

PubMed Central

Hogan, Margaret C; Saavedra-Avendano, Biani; Darney, Blair G; Torres-Palacios, Luis M; Rhenals-Osorio, Ana L; Sierra, Bertha L Vázquez; Soliz-Sánchez, Patricia N; Gakidou, Emmanuela

2016-01-01

Abstract Objective To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. Methods We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. Findings A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. Conclusion The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care. PMID:27147766

Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh.

PubMed

Begum, Tahmina; Rahman, Aminur; Nababan, Herfina; Hoque, Dewan Md Emdadul; Khan, Al Fazal; Ali, Taslim; Anwar, Iqbal

2017-01-01

Caesarean section (C-section) is a major obstetric intervention for saving lives of women and their newborns from pregnancy and childbirth related complications. Un-necessary C-sections may have adverse impact upon maternal and neonatal outcomes. In Bangladesh there is paucity of data on clinical indication of C-section at population level. We conducted a retrospective study in icddr,b Health and Demographic Surveillance System (HDSS) area of Matlab to look into the indications and determinants of C-sections. All resident women in HDSS service area who gave birth in 2013 with a known birth outcome, were included in the study. Women who underwent C-section were identified from birth and pregnancy files of HDSS and their indication for C-section were collected reviewing health facility records where the procedure took place, supplemented by face-to-face interview of mothers where data were missing. Indications of C-section were presented as frequency distribution and further divided into different groups following 3 distinct classification systems. Socio-demographic predictors were explored following statistical method of binary logistic regression. During 2013, facility delivery rate was 84% and population based C-section rate was 35% of all deliveries in icddr,b service area. Of all C-sections, only 1.4% was conducted for Absolute Maternal Indications (AMIs). Major indications of C-sections included: repeat C-section (24%), foetal distress (21%), prolonged labour (16%), oligohydramnios (14%) and post-maturity (13%). More than 80% C-sections were performed in for-profit private facilities. Probability of C-section delivery increased with improved socio-economic status, higher education, lower birth order, higher age, and with more number of Antenatal Care use and presence of bad obstetric history. Eight maternal deaths occurred, of which five were delivered by C-section. C-section rate in this area was much higher than national average as well as global recommendations. Very few of C-sections were undertaken for AMIs. Routine monitoring of clinical indication of C-section in public and private facilities is needed to ensure rational use of the procedure.

Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh

PubMed Central

Begum, Tahmina; Nababan, Herfina; Hoque, Dewan Md. Emdadul; Khan, Al Fazal; Ali, Taslim; Anwar, Iqbal

2017-01-01

Background and methods Caesarean section (C-section) is a major obstetric intervention for saving lives of women and their newborns from pregnancy and childbirth related complications. Un-necessary C-sections may have adverse impact upon maternal and neonatal outcomes. In Bangladesh there is paucity of data on clinical indication of C-section at population level. We conducted a retrospective study in icddr,b Health and Demographic Surveillance System (HDSS) area of Matlab to look into the indications and determinants of C-sections. All resident women in HDSS service area who gave birth in 2013 with a known birth outcome, were included in the study. Women who underwent C-section were identified from birth and pregnancy files of HDSS and their indication for C-section were collected reviewing health facility records where the procedure took place, supplemented by face-to-face interview of mothers where data were missing. Indications of C-section were presented as frequency distribution and further divided into different groups following 3 distinct classification systems. Socio-demographic predictors were explored following statistical method of binary logistic regression. Findings During 2013, facility delivery rate was 84% and population based C-section rate was 35% of all deliveries in icddr,b service area. Of all C-sections, only 1.4% was conducted for Absolute Maternal Indications (AMIs). Major indications of C-sections included: repeat C-section (24%), foetal distress (21%), prolonged labour (16%), oligohydramnios (14%) and post-maturity (13%). More than 80% C-sections were performed in for-profit private facilities. Probability of C-section delivery increased with improved socio-economic status, higher education, lower birth order, higher age, and with more number of Antenatal Care use and presence of bad obstetric history. Eight maternal deaths occurred, of which five were delivered by C-section. Conclusions C-section rate in this area was much higher than national average as well as global recommendations. Very few of C-sections were undertaken for AMIs. Routine monitoring of clinical indication of C-section in public and private facilities is needed to ensure rational use of the procedure. PMID:29155840

Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study.

PubMed

Jayanna, Krishnamurthy; Mony, Prem; B M, Ramesh; Thomas, Annamma; Gaikwad, Ajay; H L, Mohan; Blanchard, James F; Moses, Stephen; Avery, Lisa

2014-09-04

The maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India. We undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers' knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions. 84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets. Addressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers' clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

PubMed

Ng'anjo Phiri, Selia; Fylkesnes, Knut; Moland, Karen Marie; Byskov, Jens; Kiserud, Torvid

2016-01-01

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Maternal Health Situation in India: A Case Study

PubMed Central

Mavalankar, Dileep V.; Ramani, K.V.; Upadhyaya, Mudita; Sharma, Bharati; Iyengar, Sharad; Gupta, Vikram; Iyengar, Kirti

2009-01-01

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India's goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health. PMID:19489415

Associations between HIV, highly active anti-retroviral therapy, and hypertensive disorders of pregnancy among maternal deaths in South Africa 2011-2013.

PubMed

Sebitloane, Hannah M; Moodley, Jagidesa; Sartorius, Benn

2017-02-01

To explore potential relationships between HIV and highly active anti-retroviral therapy (HAART), and hypertensive disorders of pregnancy (HDP). A retrospective secondary analysis of maternal-deaths data from the 2011-2013 Saving Mothers Report from South Africa. The incidence of HIV infection amongst individuals who died owing to HDP was determined and comparisons were made based on HIV status and the use of HAART. Among 4452 maternal deaths recorded in the Saving Mothers report, a lower risk of a maternal deaths being due to HDP was observed among women who had HIV infections compared with women who did not have HIV (relative risk [RR] 0.57, 95% confidence interval [CI] 0.51-0.64). Further, reduced odds of death being due to HDP were recorded among women with AIDS not undergoing HAART compared with women with HIV who did not require treatment (RR 0.42, 95% CI 0.3-0.58). Notably, among all women with AIDS, a greater risk of death due to HDP was demonstrated among those who received HAART compared with those who did not (RR 1.15, 95% CI 1.02-1.29). HIV and AIDS were associated with a decreased risk of HDP being the primary cause of death; the use of HAART increased this risk. © 2016 International Federation of Gynecology and Obstetrics.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model.

PubMed

Esscher, Annika; Binder-Finnema, Pauline; Bødker, Birgit; Högberg, Ulf; Mulic-Lutvica, Ajlana; Essén, Birgitta

2014-04-12

Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010. A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Maternal health in Gujarat, India: a case study.

PubMed

Mavalankar, Dileep V; Vora, Kranti S; Ramani, K V; Raman, Parvathy; Sharma, Bharati; Upadhyaya, Mudita

2009-04-01

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness.

Point-of-Care Diagnostics for Improving Maternal Health in South Africa

PubMed Central

Mashamba-Thompson, Tivani P.; Sartorius, Benn; Drain, Paul K.

2016-01-01

Improving maternal health is a global priority, particularly in high HIV-endemic, resource-limited settings. Failure to use health care facilities due to poor access is one of the main causes of maternal deaths in South Africa. “Point-of-care” (POC) diagnostics are an innovative healthcare approach to improve healthcare access and health outcomes in remote and resource-limited settings. In this review, POC testing is defined as a diagnostic test that is carried out near patients and leads to rapid clinical decisions. We review the current and emerging POC diagnostics for maternal health, with a specific focus on the World Health Organization (WHO) quality-ASSURED (Affordability, Sensitivity, Specificity, User friendly, Rapid and robust, Equipment free and Delivered) criteria for an ideal point-of-care test in resource-limited settings. The performance of POC diagnostics, barriers and challenges related to implementing POC diagnostics for maternal health in rural and resource-limited settings are reviewed. Innovative strategies for overcoming these barriers are recommended to achieve substantial progress on improving maternal health outcomes in these settings. PMID:27589808

Why are babies born before arrival at health facilities in King Sabata Dalindyebo Local Municipality, Eastern Cape, South Africa? A qualitative study

PubMed Central

Alabi, Adeyinka A.; Wright, Graham; Ntsaba, Mohlomi J.

2015-01-01

Introduction Babies born before arrival at a health facility have a higher risk of neonatal death and their mothers a higher risk of maternal death compared with those born in-facility. The study explored the reasons for mothers giving birth before arrival (BBA) at health facilities and their experiences of BBA. Methods A qualitative research design was used. Individual and focus group interviews of BBA mothers and of nurses were undertaken at a community health centre and a district hospital in King Sabata Dalindyebo Local Municipality. Results Reasons for BBA included a lack of transport, a lack of security at night that deterred mothers from travelling, precipitate labour, failure to identify true labour, and a lack of waiting areas at health facilities. Traditional and cultural beliefs favouring childbirth at home and nurses’ negative attitudes during antenatal care and labour influenced mothers to go to health facilities when in advanced labour. Mothers were aware of possible complications associated with BBA. Conclusion Socio-economic, individual, cultural and health system factors influence the occurrence of BBA. Relevant parties need to address these factors to ensure that all babies in the King Sabata Dalindyebo Local Municipality are delivered within designated health facilities. PMID:26842514

Maternal characteristics and obstetrical complications impact neonatal outcomes in Indonesia: a prospective study.

PubMed

Anggondowati, Trisari; El-Mohandes, Ayman A E; Qomariyah, S Nurul; Kiely, Michele; Ryon, Judith J; Gipson, Reginald F; Zinner, Benjamin; Achadi, Anhari; Wright, Linda L

2017-03-28

We investigated associations between maternal characteristics, access to care, and obstetrical complications including near miss status on admission or during hospitalization on perinatal outcomes among Indonesian singletons. We prospectively collected data on inborn singletons at two hospitals in East Java. Data included socio-demographics, reproductive, obstetric and neonatal variables. Reduced multivariable models were constructed. Outcomes of interest included low and very low birthweight (LBW/VLBW), asphyxia and death. Referral from a care facility was associated with a reduced risk of LBW and VLBW [AOR = 0.28, 95% CI = 0.11-0.69, AOR = 0.18, 95% CI = 0.04-0.75, respectively], stillbirth [AOR = 0.41, 95% CI = 0.18-0.95], and neonatal death [AOR = 0.2, 95% CI = 0.05-0.81]. Mothers age <20 years increased the risk of VLBW [AOR = 6.39, 95% CI = 1.82-22.35] and neonatal death [AOR = 4.10, 95% CI = 1.29-13.02]. Malpresentation on admission increased the risk of asphyxia [AOR = 4.65, 95% CI = 2.23-9.70], stillbirth [AOR = 3.96, 95% CI = 1.41-11.15], and perinatal death [AOR = 3.89 95% CI = 1.42-10.64], as did poor prenatal care (PNC) [AOR = 11.67, 95%CI = 2.71-16.62]. Near-miss on admission increased the risk of neonatal [AOR = 11.67, 95% CI = 2.08-65.65] and perinatal death [AOR = 13.08 95% CI = 3.77-45.37]. Mothers in labor should be encouraged to seek care early and taught to identify early danger signs. Adequate PNC significantly reduced perinatal deaths. Improved hospital management of malpresentation may significantly reduce perinatal morbidity and mortality. The importance of hospital-based prospective studies helps evaluate specific areas of need in training of obstetrical care providers.

The impact of eliminating within-country inequality in health coverage on maternal and child mortality: a Lives Saved Tool analysis.

PubMed

Clermont, Adrienne

2017-11-07

Inequality in healthcare across population groups in low-income countries is a growing topic of interest in global health. The Lives Saved Tool (LiST), which uses health intervention coverage to model maternal, neonatal, and child health outcomes such as mortality rates, can be used to analyze the impact of within-country inequality. Data from nationally representative household surveys (98 surveys conducted between 1998 and 2014), disaggregated by wealth quintile, were used to create a LiST analysis that models the impact of scaling up health intervention coverage for the entire country from the national average to the rate of the top wealth quintile (richest 20% of the population). Interventions for which household survey data are available were used as proxies for other interventions that are not measured in surveys, based on co-delivery of intervention packages. For the 98 countries included in the analysis, 24-32% of child deaths (including 34-47% of neonatal deaths and 16-19% of post-neonatal deaths) could be prevented by scaling up national coverage of key health interventions to the level of the top wealth quintile. On average, the interventions with most unequal coverage rates across wealth quintiles were those related to childbirth in health facilities and to water and sanitation infrastructure; the most equally distributed were those delivered through community-based mass campaigns, such as vaccines, vitamin A supplementation, and bednet distribution. LiST is a powerful tool for exploring the policy and programmatic implications of within-country inequality in low-income, high-mortality-burden countries. An "Equity Tool" app has been developed within the software to make this type of analysis easily accessible to users.

Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania

PubMed Central

Mahiti, Gladys Reuben; Mkoka, Dickson Ally; Kiwara, Angwara Dennis; Mbekenga, Columba Kokusiima; Hurtig, Anna-Karin; Goicolea, Isabel

2015-01-01

Background Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. Design We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. Results ‘Three categories emerged that reflected women's perceptions of maternal health care services: “mothers perceive that maternal health services are beneficial,” “barriers to accessing maternal health services” such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and “ambivalence regarding the quality of maternal health services” reflecting that women had both positive and negative perceptions in relation to quality of health care services offered’. Conclusions Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women. PMID:26498576

[Prenatal care and hospital maternal mortality in Tijuana, Baja California, Mexico].

PubMed

Gonzaga-Soriano, María Rode; Zonana-Nacach, Abraham; Anzaldo-Campos, María Cecilia; Olazarán-Gutiérrez, Asbeidi

2014-01-01

To describe the prenatal care (PC) received in women with maternal hospital deaths from 2005 to 2011 in Tijuana, Baja California, Mexico. Were reviewed the medical chars and registrations of the maternal deaths by the local Committees of Maternal Mortality. There were 44 maternal hospital deaths. Thirty (68%) women assisted to PC appointments during pregnancy, the average number of PC visits was 3.8 and 18 (41%) had an adequate PC (≥ 5 visits). Six (14%) women didn't know they were pregnant; 19 (43%), 21 (48%) y 4 (9%) maternal deaths were due to direct, indirect obstetric cause or non-obstetric causes. Eighteen (18%), 2 (4 %) and 34 (77%) of the maternal deaths occurred during pregnancy, delivery or puerperium. It is necessary pregnancy women have an early, periodic and systematic PC to identify opportunely risk factors associated with pregnancy complications.

Magnitude and factors associated with institutional delivery service utilization among childbearing mothers in Cheha district, Gurage zone, SNNPR, Ethiopia: a community based cross sectional study.

PubMed

Habte, Feleke; Demissie, Meaza

2015-11-17

Ethiopia is one of the six countries that contributes' to more than 50 % of worldwide maternal deaths. While it is revealed that delivery attended by skilled provider at health facility reduced maternal deaths, more than half of all births in Ethiopia takes place at home. According to EDHS 2011 report nine women in every ten deliver at home in Ethiopia. The situation is much worse in southern region. The aim of our study is to measure the prevalence and to identify factors associated with institutional delivery service utilization among childbearing mothers in Cheha District, SNNPR, Ethiopia. A community based cross sectional survey was conducted in Cheha District from Dec 22, 2012 to Jan 11, 2013. Multistage sampling method was employed and 816 women who gave birth within the past 2 years and lived in Cheha district for minimum of one year prior to the survey were involved in the study. Data was entered and analyzed using Epi Info Version 7 and SPSS Version 16. Frequencies and binary logistic regression were done. Factors affecting institutional delivery were determined using multivariate logistic regression. A total of 31 % of women gave birth to their last child at health facility. Place of residence, ability to afford for the whole process to get delivery service at health facility, traveling time that takes to reach to health institution which provides delivery service, husband's attitude towards institutional delivery, counseling about where to deliver during ANC visit and place of birth of the 2(nd) youngest child were found to have statistically significant association with institutional delivery. Institutional delivery is low in the study area. Access to health service was found to be the most important predictor of institutional delivery among others. Accessing health facility within reasonable travel time; providing health education and BCC services to husbands and the community at large on importance of using health institution for delivery service; working to improve women's economic status; counseling women to give birth at health institution during their ANC visit and exploring the overall quality of ANC service are some of the areas where much work is needed to improve institutional delivery.

Can the right to health inform public health planning in developing countries? A case study for maternal healthcare from Indonesia

PubMed Central

D'Ambruoso, Lucia; Byass, Peter; Nurul Qomariyah, Siti

2008-01-01

Background Maternal mortality remains unacceptably high in developing countries despite international advocacy, development targets, and simple, affordable and effective interventions. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged. Objective We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal healthcare. Our objective was to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective. Design Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceased's relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death. Results In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld. Conclusion The rights-based approach could identify how and where to improve services. However, there are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning. PMID:20027244

Impact of Maternal Death on Household Economy in Rural China: A Prospective Path Analysis.

PubMed

Ye, Fang; Ao, Deng; Feng, Yao; Wang, Lin; Chen, Jie; Huntington, Dale; Wang, Haijun; Wang, Yan

2015-01-01

The present study aimed to explore the inter-relationships among maternal death, household economic status after the event, and potential influencing factors. We conducted a prospective cohort study of households that had experienced maternal death (n = 195) and those that experienced childbirth without maternal death (n = 384) in rural China. All the households were interviewed after the event occurred and were followed up 12 months later. Structural equation modeling was used to test the relationship model, utilizing income and expenditure per capita in the following year after the event as the main outcome variables, maternal death as the predictor, and direct costs, the amount of money offset by positive and negative coping strategies, whether the husband remarried, and whether the newborn was alive as the mediators. In the following year after the event, the path analysis revealed a direct effect from maternal death to lower income per capita (standardized coefficient = -0.43, p = 0.041) and to lower expenditure per capita (standardized coefficient = -0.51, p<0.001). A significant indirect effect was found from maternal death to lower income and expenditure per capita mediated by the influencing factors of higher direct costs, less money from positive coping methods, more money from negative coping, and the survival of the newborn. This study analyzed the direct and indirect effects of maternal death on a household economy. The results provided evidence for better understanding the mechanism of how this event affects a household economy and provided a reference for social welfare policies to target the most vulnerable households that have suffered from maternal deaths.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel.

PubMed

Black, Robert E; Taylor, Carl E; Arole, Shobha; Bang, Abhay; Bhutta, Zulfiqar A; Chowdhury, A Mushtaque R; Kirkwood, Betty R; Kureshy, Nazo; Lanata, Claudio F; Phillips, James F; Taylor, Mary; Victora, Cesar G; Zhu, Zonghan; Perry, Henry B

2017-06-01

The contributions that community-based primary health care (CBPHC) and engaging with communities as valued partners can make to the improvement of maternal, neonatal and child health (MNCH) is not widely appreciated. This unfortunate reality is one of the reasons why so few priority countries failed to achieve the health-related Millennium Development Goals by 2015. This article provides a summary of a series of articles about the effectiveness of CBPHC in improving MNCH and offers recommendations from an Expert Panel for strengthening CBPHC that were formulated in 2008 and have been updated on the basis of more recent evidence. An Expert Panel convened to guide the review of the effectiveness of community-based primary health care (CBPHC). The Expert Panel met in 2008 in New York City with senior UNICEF staff. In 2016, following the completion of the review, the Panel considered the review's findings and made recommendations. The review consisted of an analysis of 661 unique reports, including 583 peer-reviewed journal articles, 12 books/monographs, 4 book chapters, and 72 reports from the gray literature. The analysis consisted of 700 assessments since 39 were analyzed twice (once for an assessment of improvements in neonatal and/or child health and once for an assessment in maternal health). The Expert Panel recommends that CBPHC should be a priority for strengthening health systems, accelerating progress in achieving universal health coverage, and ending preventable child and maternal deaths. The Panel also recommends that expenditures for CBPHC be monitored against expenditures for primary health care facilities and hospitals and reflect the importance of CBPHC for averting mortality. Governments, government health programs, and NGOs should develop health systems that respect and value communities as full partners and work collaboratively with them in building and strengthening CBPHC programs - through engagement with planning, implementation (including the full use of community-level workers), and evaluation. CBPHC programs need to reach every community and household in order to achieve universal coverage of key evidence-based interventions that can be implemented in the community outside of health facilities and assure that those most in need are reached. Stronger CBPHC programs that foster community engagement/empowerment with the implementation of evidence-based interventions will be essential for achieving universal coverage of health services by 2030 (as called for by the Sustainable Development Goals recently adopted by the United Nations), ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization, UNICEF, and many countries around the world), and eventually achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978. Stronger CBPHC programs can also create entry points and synergies for expanding the coverage of family planning services as well as for accelerating progress in the detection and treatment of HIV/AIDS, tuberculosis, malaria, hypertension, and other chronic diseases. Continued strengthening of CBPHC programs based on rigorous ongoing operations research and evaluation will be required, and this evidence will be needed to guide national and international policies and programs.

Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date

PubMed Central

2013-01-01

Background Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births. Methods We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events. Results Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries. Conclusions Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication. PMID:23421792

Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date.

PubMed

Smith, Jeffrey Michael; Gubin, Rehana; Holston, Martine M; Fullerton, Judith; Prata, Ndola

2013-02-20

Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births. We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events. Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries. Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication.

Obstructed labour.

PubMed

Neilson, J P; Lavender, T; Quenby, S; Wray, S

2003-01-01

Obstructed labour is an important cause of maternal deaths in communities in which undernutrition in childhood is common resulting in small pelves in women, and in which there is no easy access to functioning health facilities with the capability of carrying out operative deliveries. Obstructed labour also causes significant maternal morbidity in the short term (notably infection) and long term (notably obstetric fistulas). Fetal death from asphyxia is also common. There are differences in the behaviour of the uterus during obstructed labour, depending on whether the woman has delivered previously. The pattern in primigravid women (typically diminishing contractility with risk of infection and fistula) may result from tissue acidosis, whereas in parous women, contractility may be maintained with the risk of uterine rupture. Ultimately, tackling the problem of obstructed labour will require universal adequate nutritional intake from childhood and the ability to access adequately equipped and staffed clinical facilities when problems arise in labour. These seem still rather distant aspirations. In the meantime, strategies should be implemented to encourage early recognition of prolonged labour and appropriate clinical responses. The sequelae of obstructed labour can be an enormous source of human misery and the prevention of obstetric fistulas, and skilled treatment if they do occur, are important priorities in regions where obstructed labour is still common.

Addressing maternal deaths due to violence: the Illinois experience.

PubMed

Koch, Abigail R; Geller, Stacie E

2017-11-01

Homicide, suicide, and substance abuse accounted for nearly one fourth of all pregnancy-associated deaths in Illinois from 2002 through 2013. Maternal mortality review in Illinois has been primarily focused on obstetric and medical causes and little is known about the circumstances surrounding deaths due to homicide, suicide, and substance abuse, if they are pregnancy related, and if the deaths are potentially preventable. To address this issue, we implemented a process to form a second statewide maternal mortality review committee for deaths due to violence in late 2014. We convened a stakeholder group to accomplish 3 tasks: (1) identify appropriate committee members; (2) identify potential types and sources of information that would be required for a meaningful review of violent maternal deaths; and (3) revise the Maternal Mortality Review Form. Because homicide, suicide, and substance abuse are closely linked to the social determinants of health, the review committee needed to have a broad membership with expertise in areas not required for obstetric maternal mortality review, including social service and community organizations. Identifying additional sources of information is critical; the state Violent Death Reporting System, case management data, and police and autopsy reports provide contextual information that cannot be found in medical records. The stakeholder group revised the Maternal Mortality Review Form to collect information relevant to violent maternal deaths, including screening history and psychosocial history. The form guides the maternal mortality review committee for deaths due to violence to identify potentially preventable factors relating to the woman, her family, systems of care, the community, the legal system, and the institutional environment. The committee has identified potential opportunities to decrease preventable death requiring cooperation with social service agencies and the criminal justice system in addition to the physical and mental health care systems. Illinois has demonstrated that by engaging appropriate members and expanding the information used, it is possible to conduct meaningful reviews of these deaths and make recommendations to prevent future deaths. Copyright © 2017 Elsevier Inc. All rights reserved.

The Effects of Maternal Mortality on Infant and Child Survival in Rural Tanzania: A Cohort Study.

PubMed

Finlay, Jocelyn E; Moucheraud, Corrina; Goshev, Simo; Levira, Francis; Mrema, Sigilbert; Canning, David; Masanja, Honorati; Yamin, Alicia Ely

2015-11-01

The full impact of a maternal death includes consequences faced by orphaned children. This analysis adds evidence to a literature on the magnitude of the association between a woman's death during or shortly after childbirth, and survival outcomes for her children. The Ifakara and Rufiji Health and Demographic Surveillance Sites in rural Tanzania conduct longitudinal, frequent data collection of key demographic events at the household level. Using a subset of the data from these sites (1996-2012), this survival analysis compared outcomes for children who experienced a maternal death (42 and 365 days definitions) during or near birth to those children whose mothers survived. There were 111 maternal deaths (or 229 late maternal deaths) during the study period, and 46.28 % of the index children also subsequently died (40.73 % of children in the late maternal death group) before their tenth birthday-a much higher prevalence of child mortality than in the population of children whose mothers survived (7.88 %, p value <0.001). Children orphaned by early maternal deaths had a 51.54 % chance of surviving to their first birthday, compared to a 94.42 % probability for children of surviving mothers. A significant, but lesser, child survival effect was also found for paternal deaths in this study period. The death of a mother compromises the survival of index children. Reducing maternal mortality through improved health care-especially provision of high-quality skilled birth attendance, emergency obstetric services and neonatal care-will also help save children's lives.

Qualitative assessment of women's satisfaction with maternal health care in referral hospitals in Nigeria.

PubMed

Okonofua, Friday; Ogu, Rosemary; Agholor, Kingsley; Okike, Ola; Abdus-Salam, Rukiyat; Gana, Mohammed; Randawa, Abdullahi; Abe, Eghe; Durodola, Adetoye; Galadanci, Hadiza

2017-03-16

Available evidence suggests that the low use of antenatal, delivery, and post-natal services by Nigerian women may be due to their perceptions of low quality of care in health facilities. This study investigated the perceptions of women regarding their satisfaction with the maternity services offered in secondary and tertiary hospitals in Nigeria. Five focus group discussions (FGDs) were held with women in eight secondary and tertiary hospitals in four of the six geo-political zones of the country. In all, 40 FGDs were held with women attending antenatal and post-natal clinics in the hospitals. The questions assessed women's level of satisfaction with the care they received in the hospitals, their views on what needed to be done to improve patients' satisfaction, and the overall quality of maternity services in the hospitals. The discussions were audio-taped, transcribed, and analyzed by themes using Atlas ti computer software. Few of the participants expressed satisfaction with the quality of care they received during antenatal, intrapartum, and postnatal care. Many had areas of dissatisfaction, or were not satisfied at all with the quality of care. Reasons for dissatisfaction included poor staff attitude, long waiting time, poor attention to women in labour, high cost of services, and sub-standard facilities. These sources of dissatisfaction were given as the reasons why women often preferred traditional rather than modern facility based maternity care. The recommendations they made for improving maternity care were also consistent with their perceptions of the gaps and inadequacies. These included the improvement of hospital facilities, re-organization of services to eliminate delays, the training and re-training of health workers, and feedback/counseling and education of women. A women-friendly approach to delivery of maternal health care based on adequate response to women's concerns and experiences of health care will be critical to curbing women's dissatisfaction with modern facility based health care, improving access to maternal health, and reducing maternal morbidity and mortality in Nigeria. Trial Registration Number NCTR No: 91540209. Nigeria Clinical Trials Registry. http://www.nctr.nhrec.net/ . Registered April 14th 2016.

From identification and review to action--maternal mortality review in the United States.

PubMed

Berg, Cynthia J

2012-02-01

The maternal mortality review process is an ongoing quality improvement cycle with 5 steps: identification of maternal deaths, collection of medical and other data on the events surrounding the death, review and synthesis of the data to identify potentially alterable factors, the development and implementation of interventions to decrease the risk of future deaths, and evaluation of the results. The most important step is utilization of the data to identify and implement evidence-based actions; without this step, the rest of the work will not have an impact. The review committee ideally is based in the health department of a state (or large city) as a core public health function. This provides stability for the process as well as facilitates implementation of the review committees' recommendations. The review committee should be multidisciplinary, with its members being official representatives of their organizations or departments, again to improve buy-in of the stakeholders. Published by Elsevier Inc.

Severe maternal morbidity and near misses in tertiary hospitals, Kelantan, Malaysia: a cross-sectional study.

PubMed

Norhayati, Mohd Noor; Nik Hazlina, Nik Hussain; Sulaiman, Zaharah; Azman, Mohd Yacob

2016-03-05

Severe maternal conditions have increasingly been used as alternative measurements of the quality of maternal care and as alternative strategies to reduce maternal mortality. We aimed to study severe maternal morbidity and maternal near miss among women in two tertiary hospitals in Kota Bharu, Kelantan, Malaysia. A cross-sectional study with record review was conducted in 2014. Severe maternal morbidity and maternal near miss were classified using the new World Health Organization criteria. Health indicators for obstetric care were calculated and descriptive analyses were performed using SPSS version 22.0. In total, 21,579 live births, 395 women with severe maternal morbidity, 47 women with maternal near miss and two maternal deaths were analysed. The severe maternal morbidity incidence ratio was 18.3 per 1000 live births and the maternal near miss incidence ratio was 2.2 per 1000 live births. The maternal near miss mortality ratio was 23.5 and the mortality index was 4.1 %. The process indicators for essential interventions were almost 100.0 %. Haemorrhagic disorders were the most common event for severe maternal morbidity (68.6 %) and maternal near miss (80.9 %) and management-based criteria accounted for 85.1 %. Comprehensive emergency care and intensive care as well as overall improvements in the quality of maternal health care need to be achieved to substantial reduce maternal death.

Satisfaction with emergency obstetric and new born care services among clients using public health facilities in Jimma Zone, Oromia Regional State, Ethiopia; a cross sectional study.

PubMed

Kumsa, Alemayehu; Tura, Gurmessa; Nigusse, Aderajew; Kebede, Getahun

2016-04-25

The 2005 report of United Nations Millennium Project of Transforming Health Systems for women and children concluded that universal access to Emergency Obstetric and New born Care could reduce maternal deaths by 74%. Even though some studies investigated quality of Emergency Obstetric and New born Care in different parts of the world, there is scarcity of data regarding this issue in Ethiopia, particularly in Jimma zone. Therefore, the aim of this study was to assess satisfaction with Emergency Obstetric and new born Care services among clients using public health facilities in Jimma zone, Southwest Ethiopia. A facility-based cross sectional study was conducted in Jimma Zone from April 01-30, 2014. The data were collected by interviewing 403 clients, who gave birth in the past 12 months prior to data collection in 34 randomly selected public health facilities. The collected data were entered by using Epi-info version 3.5.4 and analysed using SPSS version 20.0. Linear regression analysis was done to ascertain the association between covariates and the outcome variable, and finally the results were presented using frequency distribution tables, graphs and texts. The overall mean client satisfaction with Emergency Obstetric and New born Care services in this study was 79.4%; 95% CI (75%, 83%). The result of linear regression analysis revealed that a unit decrease in satisfaction to availability of drugs and equipment, decreased overall clients' satisfaction by 0.23 unit 95% CI (0.15, 0.31). The level of clients' satisfaction with Emergency Obstetric and New born Care services was low in the study area. Factors such as availability of essential equipment and drugs, health workers' communication, health care provided, and attitude of health workers had positive association with client satisfaction with Emergency Obstetric and New born Care services. This in turn could affect utilization of Emergency Obstetric and New born Care services and play a role in contribution to maternal and new born mortality. Therefore, the efforts of health facilities leaders and health care providers towards improvement of quality of care could contribute more for better maternal satisfaction.

Avoidable deaths until 48 [corrected] months of age among children from the 2004 Pelotas birth cohort.

PubMed

Gorgot, Luis Ramon Marques da Rocha; Santos, Iná; Valle, Neiva; Matijasevich, Alicia; Matisajevich, Alicia; Barros, Aluisio J D; Albernaz, Elaine

2011-04-01

To describe avoidable deaths of children from the 2004 Pelotas Birth Cohort. The death of 92 children between 2004/2008 from Pelotas Birth Cohort were identified and classified according to the Brazilian List of Avoidable Causes of Mortality of Brazilian Unified Healthcare System. The Mortality Information System (SIM) for the State of Rio Grande do Sul (Southern Brazil) and the city of Pelotas were screened to search for deaths that occurred outside the city, as well as causes of deaths after the 1st year. Causes of infant deaths (<1 year of age) were compared between information from a sub-study and SIM. Mortality coefficients per 1,000 LB and proportional mortality for avoidable causes, including by type of health facility (traditional or Family Health Strategy) were calculated. The mortality coefficient was 22.2/ 1,000 LB, 82 the deaths occurred in the first year of life (19.4/1,000LB), and these included 37 (45%) in the first week. More than ¾ of the deaths (70/92) were avoidable. In infancy, according to the sub-study, the majority (42/82) could be prevented through adequate care of the woman during pregnancy; according to SIM, the majority could have been prevented through adequate newborn care (32/82). There was no difference in the proportion of avoidable deaths by type of health facility. The proportion of avoidable deaths is high. The quality of death certificate registries needs improvement so that avoidable deaths can be employed as an indicator to monitor maternal and child health care.

Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa.

PubMed

Bradshaw, Debbie; Chopra, Mickey; Kerber, Kate; Lawn, Joy E; Bamford, Lesley; Moodley, Jack; Pattinson, Robert; Patrick, Mark; Stephen, Cindy; Velaphi, Sithembiso

2008-04-12

South Africa is one of the few developing countries with a national confidential inquiry into maternal deaths. 164 health facilities obtain audit data for stillbirths and neonatal deaths, and a new audit network does so for child deaths. Three separate reports have been published, providing valuable information about avoidable causes of death for mothers, babies, and children. These reports make health-system recommendations, many of which overlap and are intertwined with the scarcity of progress in addressing HIV/AIDS. The leaders of these three reports have united to prioritise actions to save the lives of South Africa's mothers, babies, and children. The country is off-track for the health-related Millennium Development Goals. Mortality in children younger than 5 years has increased, whereas maternal and neonatal mortality remain constant. This situation indicates the challenge of strengthening the health system because of high inequity and HIV/AIDS. Coverage of services is fairly high, but addressing the gaps in quality and equity is essential to increasing the number of lives saved. Consistent leadership and accountability to address crosscutting health system and equity issues, and to prevent mother-to-child transmission of HIV, would save tens of thousands of lives every year. Audit is powerful, but only if the data lead to action.

Infant feeding-related maternity care practices and maternal report of breastfeeding outcomes.

PubMed

Nelson, Jennifer M; Perrine, Cria G; Freedman, David S; Williams, Letitia; Morrow, Brian; Smith, Ruben A; Dee, Deborah L

2018-02-07

Evidence-based maternity practices and policies can improve breastfeeding duration and exclusivity. Maternity facilities report practices through the Maternity Practices in Infant Nutrition and Care (mPINC) survey, but individual outcomes, such as breastfeeding duration and exclusivity, are not collected. mPINC data on maternity care practices for 2009 were linked to data from the 2009 Pregnancy Risk Assessment Monitoring System (PRAMS), which collects information on mothers' behaviors and experiences around pregnancy. We calculated total mPINC scores (range 0-100). PRAMS data on any and exclusive breastfeeding at 8 weeks were examined by total mPINC score quartile. Of 15 715 women in our sample, 53.7% were breastfeeding any at 8 weeks, and 29.3% were breastfeeding exclusively. They gave birth at 1016 facilities that had a mean total mPINC score of 65/100 (range 19-99). Care dimension subscores ranged from 41 for facility discharge care to 81 for breastfeeding assistance. In multivariable analysis adjusting for covariates, a positive relationship was found between total mPINC score quartile and both any breastfeeding (quartile 2: odds ratio [OR] 1.40 [95% confidence interval {CI} 1.08-1.83], quartile 3: OR 1.50 [95% CI 1.15-1.96], quartile 4: OR 2.12 [95% CI 1.61-2.78] vs quartile 1) and exclusive breastfeeding (quartile 3: OR 1.41 [95% CI 1.04-1.90], quartile 4: OR 1.89 [95% CI 1.41-2.55] vs quartile 1) at 8 weeks. These data demonstrate that evidence-based maternity care practices and policies are associated with better breastfeeding outcomes. Maternity facilities may evaluate their practices and policies to ensure they are helping mothers achieve their breastfeeding goals. © 2018 Wiley Periodicals, Inc.

Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis.

PubMed

Worku, Abebaw Gebeyehu; Yalew, Alemayehu Worku; Afework, Mesganaw Fantahun

2013-04-15

The evaluation of all potential sources of low skilled maternal care utilization is crucial for Ethiopia. Previous studies have largely disregarded the contribution of different levels. This study was planned to assess the effect of individual, communal, and health facility characteristics in the utilization of antenatal, delivery, and postnatal care by a skilled provider. A linked facility and population-based survey was conducted over three months (January - March 2012) in twelve "kebeles" of North Gondar Zone, Amhara Region. A total of 1668 women who had births in the year preceding the survey were selected for analysis. Using a multilevel modelling, we examined the effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization. About 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services. Factors operating at individual and "kebele" levels play a significant role in determining utilization of skilled maternal health services. Interventions to create better community awareness and perception about skilled providers and their care, and ensuring the seamless performance of health care facilities have been considered crucial to improve skilled maternal services in the study area. Such interventions should target underprivileged women.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol.

PubMed

Geleto, Ayele; Chojenta, Catherine; Mussa, Abdulbasit; Loxton, Deborah

2018-04-16

Nearly 15% of all pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labor, and complications of abortion. Between 1990 and 2015, an estimated 10.7 million women died due to obstetric complications. Almost all of these deaths (99%) happened in developing countries, and 66% of maternal deaths were attributed to sub-Saharan Africa. The majority of cases of maternal mortalities can be prevented through provision of evidence-based potentially life-saving signal functions of emergency obstetric care. However, different factors can hinder women's ability to access and use emergency obstetric services in sub-Saharan Africa. Therefore, the aim of this review is to synthesize current evidence on barriers to accessing and utilizing emergency obstetric care in sub-Saharan African. Decision-makers and policy formulators will use evidence generated from this review in improving maternal healthcare particularly the emergency obstetric care. Electronic databases including MEDLINE, CINAHL, Embase, and Maternity and Infant Care will be searched for studies using predefined search terms. Articles published in English language between 2010 and 2017 with quantitative and qualitative design will be included. The identified papers will be assessed for meeting eligibility criteria. First, the articles will be screened by examining their titles and abstracts. Then, two reviewers will review the full text of the selected articles independently. Two reviewers using a standard data extraction format will undertake data extraction from the retained studies. The quality of the included papers will be assessed using the mixed methods appraisal tool. Results from the eligible studies will be qualitatively synthesized using the narrative synthesis approach and reported using the three delays model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be employed to present the findings. This systematic review will present a detailed synthesis of the evidence for barriers to access and utilization of emergency obstetric care in sub-Saharan Africa over the last 7 years. This systematic review is expected to provide clear information that can help in designing maternal health policy and interventions particularly in emergency obstetric care in sub-Saharan Africa where maternal mortality remains high. PROSPERO CRD42017074102 .

Effects of user fee exemptions on the provision and use of maternal health services: a review of literature.

PubMed

Hatt, Laurel E; Makinen, Marty; Madhavan, Supriya; Conlon, Claudia M

2013-12-01

User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAID-commissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria-based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed.

The influence of maternal health education on the place of delivery in conflict settings of Darfur, Sudan.

PubMed

Adam, Izzeldin F

2015-01-01

Armed conflict and socio-demographic characteristics of internally displaced persons (IDPs) are very important factors that influence the provision of reproductive health (RH) in humanitarian settings. Maternal health education plays a crucial role to overcome the barriers of RH care, reduce home births conducted by traditional birth attendants (TBAs), and improve increasing births in a health facility. The objectives of this study were to (1) determine the association between the place of delivery and home visits for maternal health education and (2) describe the socio-demographic characteristics of women who gave birth during the last two years. A cross-sectional study among married women aged (15-49 years old) in IDP camps. All women were subjected to intensive maternal health education at their homes for 3 years prior to the survey. A sample of 640 women who gave birth during the last two years was randomly selected. Among all women investigated, 36.9 % (95 % CI: 33.1, 40.8) reported a home-based delivery, while 63.1 % (95 % CI: 59.2, 66.9) reported a facility-based delivery. Receiving visits for maternal health education at home was associated with an estimated 43.0 % reduction in odds of giving birth at home, compared to not receiving home visits (adjusted odds ratio [ aOR] 0.57; 95 % CI: 0.35, 0.93). The level of women's education and camp of residence were important predictors for home birth. Maternal health education at home was associated with a reduction in home-based delivery performed by TBAs in the conflict-affected setting of Darfur. Our study proposes that when facility-based delivery is made available in camp's clinics, and the targeted women educated at home to refrain from home-based delivery, they will choose to undergo facility-based delivery.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model

PubMed Central

2014-01-01

Background Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988–2010. Methods A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the ‘migration three delays’ framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Results Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Conclusions Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women. PMID:24725307

Impact of Maternal Death on Household Economy in Rural China: A Prospective Path Analysis

PubMed Central

Ye, Fang; Ao, Deng; Feng, Yao; Wang, Lin; Chen, Jie; Huntington, Dale

2015-01-01

Objectives The present study aimed to explore the inter-relationships among maternal death, household economic status after the event, and potential influencing factors. Methods We conducted a prospective cohort study of households that had experienced maternal death (n = 195) and those that experienced childbirth without maternal death (n = 384) in rural China. All the households were interviewed after the event occurred and were followed up 12 months later. Structural equation modeling was used to test the relationship model, utilizing income and expenditure per capita in the following year after the event as the main outcome variables, maternal death as the predictor, and direct costs, the amount of money offset by positive and negative coping strategies, whether the husband remarried, and whether the newborn was alive as the mediators. Results In the following year after the event, the path analysis revealed a direct effect from maternal death to lower income per capita (standardized coefficient = -0.43, p = 0.041) and to lower expenditure per capita (standardized coefficient = -0.51, p<0.001). A significant indirect effect was found from maternal death to lower income and expenditure per capita mediated by the influencing factors of higher direct costs, less money from positive coping methods, more money from negative coping, and the survival of the newborn. Conclusion This study analyzed the direct and indirect effects of maternal death on a household economy. The results provided evidence for better understanding the mechanism of how this event affects a household economy and provided a reference for social welfare policies to target the most vulnerable households that have suffered from maternal deaths. PMID:26247210

Perinatal services and outcomes in Quang Ninh province, Vietnam.

PubMed

Nga, Nguyen T; Målqvist, Mats; Eriksson, Leif; Hoa, Dinh P; Johansson, Annika; Wallin, Lars; Persson, Lars-Åke; Ewald, Uwe

2010-10-01

We report baseline results of a community-based randomized trial for improved neonatal survival in Quang Ninh province, Vietnam (NeoKIP; ISRCTN44599712). The NeoKIP trial seeks to evaluate a method of knowledge implementation called facilitation through group meetings at local health centres with health staff and community key persons. Facilitation is a participatory enabling approach that, if successful, is well suited for scaling up within health systems. The aim of this baseline report is to describe perinatal services provided and neonatal outcomes. Survey of all health facility registers of service utilization, maternal deaths, stillbirths and neonatal deaths during 2005 in the province. Systematic group interviews of village health workers from all communes. A Geographic Information System database was also established. Three quarters of pregnant women had ≥3 visits to antenatal care. Two hundred and five health facilities, including 18 hospitals, provided delivery care, ranging from 1 to 3258 deliveries/year. Totally there were 17 519 births and 284 neonatal deaths in the province. Neonatal mortality rate was 16/1000 live births, ranging from 10 to 44/1000 in the different districts, with highest rates in the mountainous parts of the province. Only 8% had home deliveries without skilled attendance, but those deliveries resulted in one-fifth of the neonatal deaths. A relatively good coverage of perinatal care was found in a Vietnamese province, but neonatal mortality varied markedly with geography and level of care. A remaining small proportion of home deliveries generated a substantial part of mortality. © 2010 The Author(s)/Journal Compilation © 2010 Foundation Acta Paediatrica.

Knowledge, attitudes, and practices related to uterotonic drugs during childbirth in Karnataka, India: a qualitative research study.

PubMed

Deepak, Nitya Nand; Mirzabagi, Ellie; Koski, Alissa; Tripathi, Vandana

2013-01-01

India has the highest annual number of maternal deaths of any country. As obstetric hemorrhage is the leading cause of maternal death in India, numerous efforts are under way to promote access to skilled attendance at birth and emergency obstetric care. Current initiatives also seek to increase access to active management of the third stage of labor for postpartum hemorrhage prevention, particularly through administration of an uterotonic after delivery. However, prior research suggests widespread inappropriate use of uterotonics at facilities and in communities-for example, without adequate monitoring or referral support for complications. This qualitative study aimed to document health providers' and community members' current knowledge, attitudes, and practices regarding uterotonic use during labor and delivery in India's Karnataka state. 140 in-depth interviews were conducted from June to August 2011 in Bagalkot and Hassan districts with physicians, nurses, recently delivered women, mothers-in-law, traditional birth attendants (dais), unlicensed village doctors, and chemists (pharmacists). Many respondents reported use of uterotonics, particularly oxytocin, for labor augmentation in both facility-based and home-based deliveries. The study also identified contextual factors that promote inappropriate uterotonic use, including high value placed on pain during labor; perceived pressure to provide or receive uterotonics early in labor and delivery, perhaps leading to administration of uterotonics despite awareness of risks; and lack of consistent and correct knowledge regarding safe storage, dosing, and administration of oxytocin. These findings have significant implications for public health programs in a context of widespread and potentially increasing availability of uterotonics. Among other responses, efforts are needed to improve communication between community members and providers regarding uterotonic use during labor and delivery and to target training and other interventions to address identified gaps in knowledge and ensure that providers and pharmacists have up-to-date information regarding proper usage of uterotonic drugs.

Knowledge, Attitudes, and Practices Related to Uterotonic Drugs during Childbirth in Karnataka, India: A Qualitative Research Study

PubMed Central

Deepak, Nitya Nand; Mirzabagi, Ellie; Koski, Alissa; Tripathi, Vandana

2013-01-01

Background and Objectives India has the highest annual number of maternal deaths of any country. As obstetric hemorrhage is the leading cause of maternal death in India, numerous efforts are under way to promote access to skilled attendance at birth and emergency obstetric care. Current initiatives also seek to increase access to active management of the third stage of labor for postpartum hemorrhage prevention, particularly through administration of an uterotonic after delivery. However, prior research suggests widespread inappropriate use of uterotonics at facilities and in communities–for example, without adequate monitoring or referral support for complications. This qualitative study aimed to document health providers’ and community members’ current knowledge, attitudes, and practices regarding uterotonic use during labor and delivery in India’s Karnataka state. Methods 140 in-depth interviews were conducted from June to August 2011 in Bagalkot and Hassan districts with physicians, nurses, recently delivered women, mothers-in-law, traditional birth attendants (dais), unlicensed village doctors, and chemists (pharmacists). Results Many respondents reported use of uterotonics, particularly oxytocin, for labor augmentation in both facility-based and home-based deliveries. The study also identified contextual factors that promote inappropriate uterotonic use, including high value placed on pain during labor; perceived pressure to provide or receive uterotonics early in labor and delivery, perhaps leading to administration of uterotonics despite awareness of risks; and lack of consistent and correct knowledge regarding safe storage, dosing, and administration of oxytocin. Conclusions These findings have significant implications for public health programs in a context of widespread and potentially increasing availability of uterotonics. Among other responses, efforts are needed to improve communication between community members and providers regarding uterotonic use during labor and delivery and to target training and other interventions to address identified gaps in knowledge and ensure that providers and pharmacists have up-to-date information regarding proper usage of uterotonic drugs. PMID:23638148

Maternal and obstetrical predictors of sudden infant death syndrome (SIDS).

PubMed

Friedmann, Isabel; Dahdouh, Elias M; Kugler, Perlyne; Mimran, Gracia; Balayla, Jacques

2017-10-01

Public Health initiatives, such as the "Safe to Sleep" campaign, have traditionally targeted infants' risk factors for the prevention of Sudden Infant Death Syndrome (SIDS). However, controversy remains regarding maternal and obstetrical risk factors for SIDS. In our study, we sought out to determine both modifiable and non-modifiable obstetrical and maternal risk factors associated with SIDS. We conducted a population-based cohort study using the CDC's Linked Birth-Infant Death data from the United States for the year 2010. The impact of several obstetrical and maternal risk factors on the risk of overall infant mortality and SIDS was estimated using unconditional regression analysis, adjusting for relevant confounders. Our cohort consisted of 4,007,105 deliveries and 24,174 infant deaths during the first year of life, of which 1991 (8.2%) were due to SIDS. Prominent risk factors for SIDS included (OR [95% CI]): black race, 1.89 [1.68-2.13]; maternal smoking, 3.56 [3.18-3.99]; maternal chronic hypertension, 1.73 [1.21-2.48]; gestational hypertension, 1.51 [1.23-1.87]; premature birth <37 weeks, 2.16 [1.82-2.55]; IUGR, 2.46 [2.14-2.82]; and being a twin, 1.81 [1.43-2.29], p < 0.0001. Relative to a cohort of infants who died of other causes, risk factors with a predilection for SIDS were maternal smoking, 2.48 [2.16-2.83] and being a twin, 1.52 [1.21-1.91], p < 0.0001. Conclusions for practice: While certain socio-demographic and gestational characteristics are important risk factors, maternal smoking remains the strongest prenatal modifiable risk factor for SIDS. We recommend the continuation of Public Health initiatives that promote safe infant sleeping practices and smoking cessation during and after pregnancy.

Inequalities in Under-5 Mortality in Nigeria: Do Ethnicity and Socioeconomic Position Matter?

PubMed Central

Antai, Diddy

2011-01-01

Background Each ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria. Methods Using multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities. Results The prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care. Conclusions Ethnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities. PMID:20877142

Infection and acute respiratory distress syndrome during pregnancy: a case series of preventable maternal deaths from southern India.

PubMed

Vasudeva, Akhila; Bhat, Rajeshwari G; Ramachandran, Amar; Kumar, Pratap

2013-02-01

Acute respiratory distress syndrome (ARDS) is common among women admitted to obstetric intensive care units, and it contributes significantly, both directly and indirectly, to maternal deaths. We present a case series of ARDS in pregnant women caused by non-obstetric causes. The women were treated at a tertiary hospital in southern India. The striking features were delayed referral from the primary care unit and the lack of a primary diagnosis or treatment. Undiagnosed rheumatic heart disease, anemia, and malaria and H1N1 epidemics contributed to these cases of ARDS and maternal death. It is necessary to increase the awareness of evidence-based uniform protocols to tackle common medical complaints during pregnancy. Copyright © 2012 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Current status of pregnancy-related maternal mortality in Japan: a report from the Maternal Death Exploratory Committee in Japan.

PubMed

Hasegawa, Junichi; Sekizawa, Akihiko; Tanaka, Hiroaki; Katsuragi, Shinji; Osato, Kazuhiro; Murakoshi, Takeshi; Nakata, Masahiko; Nakamura, Masamitsu; Yoshimatsu, Jun; Sadahiro, Tomohito; Kanayama, Naohiro; Ishiwata, Isamu; Kinoshita, Katsuyuki; Ikeda, Tomoaki

2016-03-21

To clarify the problems related to maternal deaths in Japan, including the diseases themselves, causes, treatments and the hospital or regional systems. Descriptive study. Maternal death registration system established by the Japan Association of Obstetricians and Gynecologists (JAOG). Women who died during pregnancy or within a year after delivery, from 2010 to 2014, throughout Japan (N=213). The preventability and problems in each maternal death. Maternal deaths were frequently caused by obstetric haemorrhage (23%), brain disease (16%), amniotic fluid embolism (12%), cardiovascular disease (8%) and pulmonary disease (8%). The Committee considered that it was impossible to prevent death in 51% of the cases, whereas they considered prevention in 26%, 15% and 7% of the cases to be slightly, moderately and highly possible, respectively. It was difficult to prevent maternal deaths due to amniotic fluid embolism and brain disease. In contrast, half of the deaths due to obstetric haemorrhage were considered preventable, because the peak duration between the initial symptoms and initial cardiopulmonary arrest was 1-3 h. A range of measures, including individual education and the construction of good relationships among regional hospitals, should be established in the near future, to improve primary care for patients with maternal haemorrhage and to save the lives of mothers in Japan. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study.

PubMed

Ganchimeg, T; Ota, E; Morisaki, N; Laopaiboon, M; Lumbiganon, P; Zhang, J; Yamdamsuren, B; Temmerman, M; Say, L; Tunçalp, Ö; Vogel, J P; Souza, J P; Mori, R

2014-03-01

To investigate the risk of adverse pregnancy outcomes among adolescents in 29 countries. Secondary analysis using facility-based cross-sectional data of the World Health Organization Multicountry Survey on Maternal and Newborn Health. Twenty-nine countries in Africa, Latin America, Asia and the Middle East. Women admitted for delivery in 359 health facilities during 2-4 months between 2010 and 2011. Multilevel logistic regression models were used to estimate the association between young maternal age and adverse pregnancy outcomes. Risk of adverse pregnancy outcomes among adolescent mothers. A total of 124 446 mothers aged ≤24 years and their infants were analysed. Compared with mothers aged 20-24 years, adolescent mothers aged 10-19 years had higher risks of eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery and severe neonatal conditions. The increased risk of intra-hospital early neonatal death among infants born to adolescent mothers was reduced and statistically insignificant after adjustment for gestational age and birthweight, in addition to maternal characteristics, mode of delivery and congenital malformation. The coverage of prophylactic uterotonics, prophylactic antibiotics for caesarean section and antenatal corticosteroids for preterm delivery at 26-34 weeks was significantly lower among adolescent mothers. Adolescent pregnancy was associated with higher risks of adverse pregnancy outcomes. Pregnancy prevention strategies and the improvement of healthcare interventions are crucial to reduce adverse pregnancy outcomes among adolescent women in low- and middle-income countries. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Trends in Maternity Care Practice Skin-to-Skin Contact Indicators: United States, 2007-2015.

PubMed

Boundy, Ellen O; Perrine, Cria G; Barrera, Chloe M; Li, Ruowei; Hamner, Heather C

2018-05-21

Mother-infant skin-to-skin contact (SSC) immediately after birth helps transition infants to the post-uterine environment and increases the likelihood of breastfeeding initiation and duration. This study examines trends in U.S. maternity practices related to SSC, and variations by facility demographics. Data were from the Maternity Practices in Infant Nutrition and Care (mPINC) surveys (2007-2015), a biennial assessment of all U.S. maternity facilities. Facilities reported how often patients were encouraged to practice mother-infant SSC for ≥30 minutes within 1 hour of uncomplicated vaginal birth and 2 hours of uncomplicated cesarean birth, and how often routine infant procedures are performed while in SSC. We calculated the percentage of maternity facilities reporting these indicators for ≥90% of patients across the United States for each survey year. Estimates by facility characteristics (size, type, and state) were calculated for 2015 only. The percentage of facilities reporting "Most (≥90%)" women, which were encouraged to practice early SSC, increased from 2007 to 2015 following both vaginal (40.4% to 83.0%) and cesarean (29.3% to 69.9%) births. The percentage of facilities reporting routine infant procedures were performed "Almost always (≥90%)," while mother and infant were SSC increased from 16.6% to 49.5% (2007 to 2015) for vaginal births and from 2.2% to 10.7% (2009 to 2015) for cesarean births. Variations in SSC practice by facility type, size, and state were noted. Significant progress has been made in increasing hospital encouragement of early SSC for both vaginal and cesarean births. Continued efforts to support evidence-based maternity practices are needed.

A cross sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria.

PubMed

Bashour, Hyam; Saad-Haddad, Ghada; DeJong, Jocelyn; Ramadan, Mohammed Cherine; Hassan, Sahar; Breebaart, Miral; Wick, Laura; Hassanein, Nevine; Kharouf, Mayada

2015-11-13

The maternal near-miss approach has been increasingly used as a tool to evaluate and improve the quality of care in maternal health. We report findings from the formative stage of a World Health Organization (WHO) funded implementation research study that was undertaken to collect primary data at the facility level on the prevalence, characteristics, and management of maternal near-miss cases in four major public referral hospitals - one each in Egypt, Lebanon, Palestine and Syria. We conducted a cross sectional study of maternal near-miss cases in the four contexts beginning in 2011, where we collected data on severe maternal morbidity in the four study hospitals, using the WHO form (Individual Form HRP A65661). In each hospital, a research team including trained hospital healthcare providers carried out the data collection. A total of 9,063 live birth deliveries were reported during the data collection period across the four settings, with a total of 77 cases of severe maternal outcomes (71 maternal near-miss cases and 6 maternal deaths). Higher indices for the maternal mortality index were found in both Al Galaa hospital, in Egypt (8.6%) and Dar Al Tawleed hospital in Syria (14.3%), being large referral hospitals, compared to Ramallah hospital in Palestine and Rafik Hariri University hospital in Lebanon. Compared to the WHO's Multicountry Survey using the same data collection tool, our study's mortality indices are higher than the index of 5.6% among countries with a moderate maternal mortality ratio in the WHO Survey. Overall, haemorrhage-related complications were the most frequent conditions among maternal near-miss cases across the four study hospitals. In all hospitals, coagulation dysfunctions (76.1%) were the most prevalent dysfunction among maternal near-miss cases, followed by cardiovascular dysfunctions. The coverage of key evidence-based interventions among women experiencing a near-miss was either universal or very high in the study hospitals. Findings from this formative stage confirmed the need for quality improvement interventions. The high reported coverage of the main clinical interventions in the study hospitals would appear to be in contradiction with the above findings as the level of coverage of key evidence-based interventions was high.

Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy.

PubMed

Aradeon, Susan B; Doctor, Henry V

2016-01-01

The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support structures. Innovative communication body tools and the rote learning Rapid Imitation Practice training methodology enabled low-literate volunteers to saturate their communities with informed group discussions transferring communication capacity and ownership to the discussion participants. CCER is especially efficient because virtually every timely, community referral for emergency maternal care results in a saved life, whereas on average, only one in every eight births delivered by an SBA (12%) is expected to be a delivery-associated complication requiring lifesaving care.

Effectiveness of the WHO SCC on improving adherence to essential practices during childbirth, in resource constrained settings.

PubMed

Kumar, Somesh; Yadav, Vikas; Balasubramaniam, Sudharsanam; Jain, Yashpal; Joshi, Chandra Shekhar; Saran, Kailash; Sood, Bulbul

2016-11-08

India accounts for 27 % of world's neonatal deaths. Although more Indian women deliver in facilities currently than a decade ago, early neonatal mortality has not declined, likely because of insufficient quality of care. The WHO Safe Childbirth Checklist (SCC) was developed to support health workers to perform essential practices known to reduce preventable maternal and new-born deaths around the time of childbirth. Despite promising early research many outstanding questions remain about effectiveness of the SCC in low-resource settings. In collaboration with the Ministry of Health SCC was modified for Indian context and introduced in 101 intervention facilities in Rajasthan, India and 99 facilities served as comparison to study if it reduces mortality. This Quasi experimental Observational intervention-comparison was embedded in this larger program to test whether a program for introduction of SCC with simple implementation package was associated with increased adherence to 28 evidence-based practices. This study was conducted in 8 intervention and 8 comparison sites. Program interventions to promote appropriate use of the SCC included orienting providers to the checklist, modest modifications of the SCC to promote provider uptake and accountability, ensuring availability of essential supplies, and providing supportive supervision for helping providers in using the SCC. The SCC was used by providers in 86 % of 240 deliveries observed in the eight intervention facilities. Providers in the intervention group significantly adhered to practices included in the SCC than providers in the comparison group controlling for baseline scores and confounders. Women delivering in the intervention facilities received on an average 11.5 more of the 28 practices included compared with women in the comparison facilities. For selected practices provider performance in the intervention group increased as much as 93 % than comparison sites. Use of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.

Maternal Health in Gujarat, India: A Case Study

PubMed Central

Vora, Kranti S.; Ramani, K.V.; Raman, Parvathy; Sharma, Bharati; Upadhyaya, Mudita

2009-01-01

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness. PMID:19489418

Ethiopia's assessment of emergency obstetric and newborn care: setting the gold standard for national facility-based assessments.

PubMed

Keyes, Emily B; Haile-Mariam, Abonesh; Belayneh, Neghist T; Gobezie, Wasihun A; Pearson, Luwei; Abdullah, Muna; Kebede, Henok

2011-10-01

To describe the methods used to implement Ethiopia's 2008 emergency obstetric and newborn care services (EmONC) assessment; highlight how the collaborative process contributed to immediate integration of results into national and subnational planning; and explain how the experience informed the development of a set of tools providing best practices and guidelines for other countries conducting similar assessments. A team of maternal and newborn health experts from the Federal Ministry of Health (FMOH), the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA), together with representatives from the Ethiopian Society of Obstetricians and Gynecologists, provided technical guidance for the 18-month process and facilitated demand for and use of the assessment results. Eighty-four trained data collectors administered 9 data collection modules in 806 public and private facilities. Field work and data were managed by a private firm who, together with the core team, implemented a multi-layered plan for data quality. Columbia University's Averting Maternal Death and Disability Program provided technical assistance. Results were published in national and regional reports and in 1-page facility factsheets informing subnational planning activities. Assessment results-which have been published in journal articles-informed water infrastructure improvements, efforts to expand access to magnesium sulfate, and FMOH and UN planning documents. The assessment also established a permanent database for future monitoring of the health system, including geographic locations of surveyed facilities. Ethiopia's assessment was successful largely because of active local leadership, a collaborative process, ample financial and technical support, and rapid integration of results into health system planning. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Implementation research to improve quality of maternal and newborn health care, Malawi.

PubMed

Brenner, Stephan; Wilhelm, Danielle; Lohmann, Julia; Kambala, Christabel; Chinkhumba, Jobiba; Muula, Adamson S; De Allegri, Manuela

2017-07-01

To evaluate the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. We conducted a non-randomized controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. We assessed changes in the facilities' essential drug stocks, equipment maintenance and clinical obstetric care processes. Difference-in-difference regression models were used to analyse effects of the scheme on adherence to obstetric care treatment protocols and provision of essential drugs, supplies and equipment. We observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. We observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants' adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care.

The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial

PubMed Central

2012-01-01

Background Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4. Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions, but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture, health system and policy environment is different. In Uganda, health outcomes are poor for both mothers and newborn babies. Policy opportunities for neonatal health include the new national Health Sector Strategic Plan, which now prioritizes newborn health including use of a community model through Village Health Teams (VHT). The aim of the present study is to adapt, develop and cost an integrated maternal-newborn care package that links community and facility care, and to evaluate its effect on maternal and neonatal practices in order to inform policy and scale-up in Uganda. Methods/Design Through formative research around evidence-based practices, and dialogue with policy and technical advisers, we constructed a home-based neonatal care package implemented by the responsible VHT member, effectively a Community Health Worker (CHW). This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered. The project is improving care in health units to provide standardized care for the mother and the newborn in both intervention and comparison areas. The study is taking place in a new Demographic Surveillance Site in two rural districts, Iganga and Mayuge, in Uganda. It is a two-arm cluster randomized controlled design with 31 intervention and 32 control areas (villages). The comparison parishes receive the standard care already being provided by the district, but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period. Both areas benefit from a standardized strengthening of facility care for mothers and neonates. Discussion UNEST is designed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy, thereby helping to inform scale-up in rural Uganda. The study is registered as a randomized controlled trial, number ISRCTN50321130. PMID:23153395

Maternal-related deaths and impoverishment among adolescent girls in India and Niger: findings from a modelling study

PubMed Central

Verguet, Stéphane; Nandi, Arindam; Filippi, Véronique; Bundy, Donald A P

2016-01-01

Background High levels of maternal mortality and large associated inequalities exist in low-income and middle-income countries. Adolescent pregnancies remain common, and pregnant adolescent women face elevated risks of maternal mortality and poverty. We examined the distribution across socioeconomic groups of maternal deaths and impoverishment among adolescent girls (15–19 years old) in Niger, which has the highest total fertility rate globally, and India, which has the largest number of maternal deaths. Methods In Niger and India, among adolescent girls, we estimated the distribution per income quintile of: the number of maternal deaths; and the impoverishment, measured by calculating the number of cases of catastrophic health expenditure incurred, caused by complicated pregnancies. We also examined the potential impact on maternal deaths and poverty of increasing adolescent girls' level of education by 1 year. We used epidemiological and cost inputs sourced from surveys and the literature. Results The number of maternal deaths would be larger among the poorer adolescents than among the richer adolescents in Niger and India. Impoverishment would largely incur among the richer adolescents in Niger and among the poorer adolescents in India. Increasing educational attainment of adolescent girls might avert both a large number of maternal deaths and a significant number of cases of catastrophic health expenditure in the 2 countries. Conclusions Adolescent pregnancies can lead to large equity gaps and substantial impoverishment in low-income and middle-income countries. Increasing female education can reduce such inequalities and provide financial risk protection and poverty alleviation to adolescent girls. PMID:27670517

Classification of deaths in women with human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth.

PubMed

Brayner, Manuella Coutinho; Alves, Sandra Valongueiro

2017-01-01

To reclassify deaths of women infected with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth in the State of Pernambuco, Brazil, from 2000 to 2010. A descriptive exploratory study, developed from the following steps: translation to Portuguese of the item "HIV and aids" of the United Nations document "The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: DCI MM 2012"; development of a classification algorithm of deaths of women living with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth; and reclassification of deaths by a group of experts. Among the 25 reclassified deaths, 12 were due to human immunodeficiency virus/acquired immunodeficiency syndrome, and pregnancy condition was coexisting; 9 were reclassified as indirect maternal death, with O98.7 code, proposed by the World Health Organization; 2 as direct/indirect maternal death; and 2 were considered indeterminate. The reclassification showed a possible pattern of change in maternal mortality, since most of the deaths were attributed to the virus and may lead to a reduction in deaths from maternal causes. The algorithm will subsidize the use of the new classification of maternal death and human immunodeficiency virus/acquired immunodeficiency syndrome.

Impact of health systems strengthening on coverage of maternal health services in Rwanda, 2000-2010: a systematic review.

PubMed

Bucagu, Maurice; Kagubare, Jean M; Basinga, Paulin; Ngabo, Fidèle; Timmons, Barbara K; Lee, Angela C

2012-06-01

From 2000 to 2010, Rwanda implemented comprehensive health sector reforms to strengthen the public health system, with the aim of reducing maternal and newborn deaths in line with Millennium Development Goal 5, among many other improvements in national health. Based on a systematic review of the literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010), this paper describes the reforms and the policies they were based on, and provides data on the extent of Rwanda's progress in expanding the coverage of four key women's health services. Progress took place in 2000-2005 and became more rapid after 2006, mostly in rural areas, when the national facility-based childbirth policy, performance-based financing, and community-based health insurance were scaled up. Between 2006 and 2010, the following increases in coverage took place as compared to 2000-2005, particularly in rural areas, where most poor women live: births with skilled attendance (77% increase vs. 26%), institutional delivery (146% increase vs. 8%), and contraceptive prevalence (351% increase vs. 150%). The primary factors in these improvements were increases in the health workforce and their skills, performance-based financing, community-based health insurance, and better leadership and governance. Further research is needed to determine the impact of these changes on health outcomes in women and children. Copyright © 2012 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.

An exploration of the socio-economic profile of women and costs of receiving abortion services at public health facilities of Madhya Pradesh, India.

PubMed

Banerjee, Sushanta K; Kumar, Rakesh; Warvadekar, Janardan; Manning, Vinoj; Andersen, Kathryn Louise

2017-03-21

Maternal mortality, which primarily burdens developing countries, reflects the greatest health divide between rich and poor. This is especially pronounced for access to safe abortion services which alone avert 1 of every 10 maternal deaths in India. Primarily due to confidentiality concerns, poor women in India prefer private services which are often offered by untrained providers and may be expensive. In 2006 the state government of Madhya Pradesh (population 73 million) began a concerted effort to ensure access to safe abortion services at public health facilities to both rural and urban poor women. This study aims to understand the socio-economic profile of women seeking abortion services in public health facilities across this state and out of pocket cost accessing abortion services. In particular, we examine the level of access that poor women have to safe abortion services in Madhya Pradesh. This study consisted of a cross-sectional client follow-up design. A total of 19 facilities were selected using two-stage random sampling and 1036 women presenting to chosen facilities with abortion and post-abortion complications were interviewed between May and December 2014. A structured data collection tool was developed. A composite wealth index computed using principal component analysis derived weights from consumer durables and asset holding and classified women into three categories, poor, moderate, and rich. Findings highlight that overall 57% of women who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for postabortion complications (67%) than induced abortion. Women reported spending no money to access abortion services as abortion services are free of cost at public facilities. However, poor women spend INR 64 (1 USD) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food. Improved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion.

Primary birthing attendants and birth outcomes in remote Inuit communities--a natural "experiment" in Nunavik, Canada.

PubMed

Simonet, F; Wilkins, R; Labranche, E; Smylie, J; Heaman, M; Martens, P; Fraser, W D; Minich, K; Wu, Y; Carry, C; Luo, Z-C

2009-07-01

There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural "experiment", birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities. A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at > or =28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda.

PubMed

Alfonso, Y Natalia; Bishai, David; Bua, John; Mutebi, Aloysius; Mayora, Crispus; Ekirapa-Kiracho, Elizabeth

2015-02-01

The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.

Trends in maternal deaths in HIV-infected women, on a background of changing HIV management guidelines in South Africa: 1997 to 2015.

PubMed

Mnyani, Coceka N; Buchmann, Eckhart J; Chersich, Matthew F; Frank, Karlyn A; McIntyre, James A

2017-11-01

As work begins towards the Sustainable Development Goal target of reducing the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030, much needs to be done in ending preventable maternal deaths. After 1990, South Africa experienced a reversal of gains in decreasing maternal mortality, with an increase in HIV-related maternal deaths. In this study, we assessed trends in maternal mortality in HIV-infected women, on a background of an evolving HIV care programme. This was a cross-sectional, retrospective record review of maternal deaths in the obstetrics unit at Chris Hani Baragwanath Academic Hospital, in Johannesburg, South Africa, a referral hospital in a high HIV prevalence setting where the prevalence among pregnant women has plateaued around 29.0% for the past decade. Trends in HIV diagnosis and management in pregnancy, and causes of maternal deaths in HIV-infected women were analysed over different time periods (1997 to 2003, 2004 to 2009, 2010 to 2012, and 2013 to 2015) reflecting major guideline changes. From January 1997 to December 2015, there were 692 maternal deaths in the obstetrics unit. Of the 490 (70.8%) maternal deaths with a documented HIV status, 335 (68.4%) were HIV-infected. A Chi-squared test for trends showed that the institutional MMR (iMMR) in women known to be HIV-infected peaked in the period 2004 to 2009 at 380 (95% CI 319 to 446) per 100,000 live births, with a decline to 267 (95% CI 198 to 353) in 2013 to 2015, p = 0.049. This decrease coincided with changes in the South African HIV management guidelines, mainly increased availability of antiretroviral therapy (ART). Non-pregnancy related infections were the leading cause of death throughout the review period, accounting for 61.5% (206/335) of deaths. Only 23.3% (78/335) of the women who died were on ART at the time of death, this in the context of advanced immune suppression and an overall median CD4 count of 136 cells/μl (interquartile ranges (IQR) 45 to 301). In this 19-year review of maternal deaths in Johannesburg, South Africa, there was evidence of a decrease in the iMMR among HIV-infected women, but it remains unacceptably high. Efforts to address drivers of mortality and barriers to accessing ART need to be accelerated if we are to see substantial decreases in maternal mortality. © 2017 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis

PubMed Central

2013-01-01

Background The evaluation of all potential sources of low skilled maternal care utilization is crucial for Ethiopia. Previous studies have largely disregarded the contribution of different levels. This study was planned to assess the effect of individual, communal, and health facility characteristics in the utilization of antenatal, delivery, and postnatal care by a skilled provider. Methods A linked facility and population-based survey was conducted over three months (January - March 2012) in twelve “kebeles” of North Gondar Zone, Amhara Region. A total of 1668 women who had births in the year preceding the survey were selected for analysis. Using a multilevel modelling, we examined the effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization. Result About 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services. Conclusion Factors operating at individual and “kebele” levels play a significant role in determining utilization of skilled maternal health services. Interventions to create better community awareness and perception about skilled providers and their care, and ensuring the seamless performance of health care facilities have been considered crucial to improve skilled maternal services in the study area. Such interventions should target underprivileged women. PMID:23587369

The importance of cardiovascular pathology contributing to maternal death: Confidential Enquiry into Maternal Deaths in South Africa, 2011–2013

PubMed Central

Soma-Pillay, Priya; Seabe, Joseph; Soma-Pillay, Priya; Seabe, Joseph; Sliwa, Karen

2016-01-01

Summary Aims Cardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higher-income countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided. Methods Data collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011–2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis. Results Peripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%). Conclusion The pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects. PMID:26895406

Quality maternity care for every woman, everywhere: a call to action.

PubMed

Koblinsky, Marjorie; Moyer, Cheryl A; Calvert, Clara; Campbell, James; Campbell, Oona M R; Feigl, Andrea B; Graham, Wendy J; Hatt, Laurel; Hodgins, Steve; Matthews, Zoe; McDougall, Lori; Moran, Allisyn C; Nandakumar, Allyala K; Langer, Ana

2016-11-05

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability. Copyright © 2016 Elsevier Ltd. All rights reserved.

Review of emergency obstetric care interventions in health facilities in the Upper East Region of Ghana: a questionnaire survey.

PubMed

Kyei-Onanjiri, Minerva; Carolan-Olah, Mary; Awoonor-Williams, John Koku; McCann, Terence V

2018-03-15

Maternal morbidity and mortality is most prevalent in resource-poor settings such as sub-Saharan Africa and southern Asia. In sub-Saharan Africa, Ghana is one of the countries still facing particular challenges in reducing its maternal morbidity and mortality. Access to emergency obstetric care (EmOC) interventions has been identified as a means of improving maternal health outcomes. Assessing the range of interventions provided in health facilities is, therefore, important in determining capacity to treat obstetric emergencies. The aim of this study was to examine the availability of emergency obstetric care interventions in the Upper East Region of Ghana. A cross-sectional survey of 120 health facilities was undertaken. Status of emergency obstetric care was assessed through an interviewer administered questionnaire to directors/in-charge officers of maternity care units in selected facilities. Data were analysed using descriptive statistics. Eighty per cent of health facilities did not meet the criteria for provision of emergency obstetric care. Comparatively, private health facilities generally provided EmOC interventions less frequently than public health facilities. Other challenges identified include inadequate skill mix of maternity health personnel, poor referral processes, a lack of reliable communication systems and poor emergency transport systems. Multiple factors combine to limit women's access to a range of essential maternal health services. The availability of EmOC interventions was found to be low across the region; however, EmOC facilities could be increased by nearly one-third through modest investments in some existing facilities. Also, the key challenges identified in this study can be improved by enhancing pre-existing health system structures such as Community-based Health Planning and Services (CHPS), training more midwifery personnel, strengthening in-service training and implementation of referral audits as part of health service monitoring. Gaps in availability of EmOC interventions, skilled personnel and referral processes must be tackled in order to improve obstetric outcomes.

Casas Maternas in the Rural Highlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population

PubMed Central

Stollak, Ira; Valdez, Mario; Rivas, Karin; Perry, Henry

2016-01-01

ABSTRACT Background: An international NGO, with financial and managerial support from “partner” communities, established Casas Maternas (birthing facilities) in 3 municipalities in the isolated northwestern highlands of the department of Huehuetenango in Guatemala—an area with high maternal mortality ratio (338 maternal deaths per 100,000 live births). Traditional birth attendants are encouraged to bring patients for delivery at the Casas Maternas, where trained staff are present and access to referral care is facilitated. Methods: We conducted a mixed-methods study in San Sebastian Coatán municipality to assess the contribution of 2 Casas Maternas to health facility deliveries among partner and non-partner communities, with particular emphasis on equity in access. We surveyed all women who delivered in the study area between April 2013 and March 2014, the first full year in which both Casas Maternas in the study area were operating. In addition, using purposive sampling, we conducted in-depth interviews with 22 women who delivered and 6 focus group discussions with 42 community leaders, traditional birth attendants, and Casas Maternas staff members. We analyzed the quantitative data using descriptive statstics and the qualitative data with descriptive content analysis. Results: Of the 321 women eligible for inclusion in the study, we surveyed 275 women (14.3% could not be located or refused to participate). Between April 2013 and March 2014, 70% of women living in partner communities delivered in a health facility (54% in a Casa Materna) compared with 30% of women living in non-partner communities (17% in a Casa Materna). There was no statistically significant difference in uptake of the Casa Materna by maternal education and only a weak effect by household wealth. In contrast, distance from the Casa Materna had a pronounced effect. Traditional birth attendants were strong advocates for utilization of the Casa Materna and played an important role in the decision regarding where the birth would take place. In addition, the program’s outreach component, in which peer volunteers visit homes to promote healthy behaviors and appropriate use of health facilities, was identified as a key factor in encouraging mothers to deliver in facilities. Discussion: The Casa Materna approach to strengthening maternity care as developed by Curamericas has potential to increase health facility utilization in isolated mountainous areas inhabited by an indigenous population where access to government services is limited and where maternal mortality is high. The approach shows promise for broader application in Guatemala and beyond. PMID:27016548

Casas Maternas in the Rural Highlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population.

PubMed

Stollak, Ira; Valdez, Mario; Rivas, Karin; Perry, Henry

2016-03-01

An international NGO, with financial and managerial support from "partner" communities, established Casas Maternas (birthing facilities) in 3 municipalities in the isolated northwestern highlands of the department of Huehuetenango in Guatemala-an area with high maternal mortality ratio (338 maternal deaths per 100,000 live births). Traditional birth attendants are encouraged to bring patients for delivery at the Casas Maternas, where trained staff are present and access to referral care is facilitated. We conducted a mixed-methods study in San Sebastian Coatán municipality to assess the contribution of 2 Casas Maternas to health facility deliveries among partner and non-partner communities, with particular emphasis on equity in access. We surveyed all women who delivered in the study area between April 2013 and March 2014, the first full year in which both Casas Maternas in the study area were operating. In addition, using purposive sampling, we conducted in-depth interviews with 22 women who delivered and 6 focus group discussions with 42 community leaders, traditional birth attendants, and Casas Maternas staff members. We analyzed the quantitative data using descriptive statstics and the qualitative data with descriptive content analysis. Of the 321 women eligible for inclusion in the study, we surveyed 275 women (14.3% could not be located or refused to participate). Between April 2013 and March 2014, 70% of women living in partner communities delivered in a health facility (54% in a Casa Materna) compared with 30% of women living in non-partner communities (17% in a Casa Materna). There was no statistically significant difference in uptake of the Casa Materna by maternal education and only a weak effect by household wealth. In contrast, distance from the Casa Materna had a pronounced effect. Traditional birth attendants were strong advocates for utilization of the Casa Materna and played an important role in the decision regarding where the birth would take place. In addition, the program's outreach component, in which peer volunteers visit homes to promote healthy behaviors and appropriate use of health facilities, was identified as a key factor in encouraging mothers to deliver in facilities. The Casa Materna approach to strengthening maternity care as developed by Curamericas has potential to increase health facility utilization in isolated mountainous areas inhabited by an indigenous population where access to government services is limited and where maternal mortality is high. The approach shows promise for broader application in Guatemala and beyond. © Stollak et al.

Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.

PubMed

Alkema, Leontine; Chou, Doris; Hogan, Daniel; Zhang, Sanqian; Moller, Ann-Beth; Gemmill, Alison; Fat, Doris Ma; Boerma, Ties; Temmerman, Marleen; Mathers, Colin; Say, Lale

2016-01-30

Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100,000 livebirths globally by 2030. We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100,000 livebirths (80% UI 359-427) in 1990, to 216 (207-249) in 2015, corresponding to a relative decline of 43·9% (34·0-48·7), with 303,000 (291,000-349,000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1·8% (0·0-3·1) in the Caribbean to 5·0% (4·0-6·0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100,000 livebirths (11-14) for high-income regions to 546 (511-652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7·5%. Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country-specific SDG targets are ambitious for most high mortality countries, countries that made a concerted effort to reduce maternal mortality between 2000 and 2010 provide inspiration and guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. National University of Singapore, National Institute of Child Health and Human Development, USAID, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction. Copyright © 2016 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd.. All rights reserved.

Maternal mortality in developing countries.

PubMed

Harrison, K A

1989-01-01

A commentary on the state of maternal mortality is developing countries is presented. Of the estimated half million maternal deaths worldwide yearly, 150,000 occur in Africa, 282,000 in Southern and South Eastern Asia, 26,000 in Western and East Asia, 34,000 in tropical South America, 1,000 in temperate South America, and 2,000 in Oceania. 494,000 maternal deaths occur in developing countries, with 6,000 in all developing countries. Maternal death rates are highest in developing countries due primarily to flaws in the social, economic, and political conditions of the countries involved, combined with a grossly inadequate quantity and quality of available health care services. Here, major causes of maternal death include abortion, anemia, eclampsia, infection, hemorrhage, and obstructed labor and its accompanying complications. Attempts at lowering maternal mortality should include health intervention policies on a global scale, utilizing the intervention of developing countries with their necessary financial and technological support. Universal formal education appears to be the most effective weapon against maternal death. This approach is an effort to modernize most developing societies. Still, a few obstacles remain. These include: discarding cherished traditional customs of health care in favor of modernized techniques, restricting existing health services, and providing faster and more efficient operative intervention procedures. Family planning is also stressed as an important initiative. The most contentious of all methods to lower maternal death rates is the retraining of illiterate traditional birth attendants (TBAs). Activities of TBAs should be viewed cautiously as results of the techniques - in areas such as the Sudan, Africa, and Asia, - have proven to be of little consequence in lowering maternal mortality. Attention to retraining TBAs should be replaced with sufficient training and proper utilization of midwives. The Royal College of Obstetricians and Gynecologists has undertaken pioneering efforts towards lowering global maternal mortality.

Newborn survival in Pakistan: a decade of change and future implications.

PubMed

Khan, Amanullah; Kinney, Mary V; Hazir, Tabish; Hafeez, Assad; Wall, Stephen N; Ali, Nabeela; Lawn, Joy E; Badar, Asma; Khan, Ali Asghar; Uzma, Qudsia; Bhutta, Zulfiqar A

2012-07-01

Pakistan has the world's third highest national number of newborn deaths (194 000 in 2010). Major national challenges over the past decade have affected health and development including several large humanitarian disasters, destabilizing political insurgency, high levels of poverty and an often hard-to-reach predominately rural population with diverse practices. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Neonatal mortality declined by only 0.9% per annum between 2000 and 2010; less than the global average (2.1%) and less than national maternal and child mortality declines. Coverage of newborn care interventions increased marginally, with wide socio-economic variations. There was little focus on newborn health until 2000 when considerable policy change occurred, including integration of newborn care into existing community-based maternal and child packages delivered by the Lady Health Worker Programme and national behaviour change communications strategies and programmes. The National Maternal, Newborn and Child Health Programme catalyzed newborn services at both facility and community levels. Civil society and academics have linked with government and several research studies have been highly influential. Since 2005, donor funding mentioning the term 'newborn' has increased more for Pakistan than for other countries. The country faces ongoing challenges in reducing neonatal mortality, and in much of Pakistan, societal norms discourage care-seeking and many women are unable to access care for themselves or their children. The policy advances and existing delivery platforms offer the potential to substantially accelerate progress in reducing neonatal deaths. The recent decision to dismantle the national Ministry of Health and devolve responsibility for health sector management to the provincial level presents both challenges and opportunities for newborn health.

Institutional Delivery Service Utilization among Women from Rural Districts of Wolaita and Dawro Zones, Southern Ethiopia; a Community Based Cross-Sectional Study

PubMed Central

Arba, Mihiretu Alemayehu; Darebo, Tadele Dana; Koyira, Mengistu Meskele

2016-01-01

Introduction The highest number of maternal deaths occur during labour, delivery and the first day after delivery highlighting the critical need for good quality care during this period. Therefore, for the strategies of institutional delivery to be effective, it is essential to understand the factors that influence individual and household factors to utilize skilled birth attendance and institutions for delivery. This study was aimed to assess factors affecting the utilization of institutional delivery service of women in rural districts of Wolaita and Dawro Zones. Methods A community based cross-sectional study was done among mothers who gave birth within the past one year preceding the survey in Wolaita and Dawro Zones, from February 01 –April 30, 2015 by using a three stage sampling technique. Initially, 6 districts were selected randomly from the total of 17 eligible districts. Then, 2 kebele from each district was selected randomly cumulating a total of 12 clusters. Finally, study participants were selected from each cluster by using systematic sampling technique. Accordingly, 957 mothers were included in the survey. Data was collected by using a pretested interviewer administered structured questionnaire. The questionnaire was prepared by including socio-demographic variables and variables of maternal health service utilization factors. Data was entered using Epi-data version 1.4.4.0 and exported to SPSS version 20 for analysis. Bivariate and multiple logistic regressions were applied to identify candidate and predictor variables respectively. Result Only 38% of study participants delivered the index child at health facility. Husband’s educational status, wealth index, average distance from nearest health facility, wanted pregnancy, agreement to follow post-natal care, problem faced during delivery, birth order, preference of health professional for ante-natal care and maternity care were predictors of institutional delivery. Conclusion The use of institutional delivery service is low in the study community. Eventhough antenatal care service is high; nearly two in every three mothers delivered their index child out of health facility. Improving socio-economic status of mothers as well as availing modern health facilities to the nearest locality will have a good impact to improve institutional delivery service utilization. Similarly, education is also a tool to improve awareness of mothers and their husbands for the improvement of health care service utilization. PMID:26986563

Institutional Delivery Service Utilization among Women from Rural Districts of Wolaita and Dawro Zones, Southern Ethiopia; a Community Based Cross-Sectional Study.

PubMed

Arba, Mihiretu Alemayehu; Darebo, Tadele Dana; Koyira, Mengistu Meskele

2016-01-01

The highest number of maternal deaths occur during labour, delivery and the first day after delivery highlighting the critical need for good quality care during this period. Therefore, for the strategies of institutional delivery to be effective, it is essential to understand the factors that influence individual and household factors to utilize skilled birth attendance and institutions for delivery. This study was aimed to assess factors affecting the utilization of institutional delivery service of women in rural districts of Wolaita and Dawro Zones. A community based cross-sectional study was done among mothers who gave birth within the past one year preceding the survey in Wolaita and Dawro Zones, from February 01 -April 30, 2015 by using a three stage sampling technique. Initially, 6 districts were selected randomly from the total of 17 eligible districts. Then, 2 kebele from each district was selected randomly cumulating a total of 12 clusters. Finally, study participants were selected from each cluster by using systematic sampling technique. Accordingly, 957 mothers were included in the survey. Data was collected by using a pretested interviewer administered structured questionnaire. The questionnaire was prepared by including socio-demographic variables and variables of maternal health service utilization factors. Data was entered using Epi-data version 1.4.4.0 and exported to SPSS version 20 for analysis. Bivariate and multiple logistic regressions were applied to identify candidate and predictor variables respectively. Only 38% of study participants delivered the index child at health facility. Husband's educational status, wealth index, average distance from nearest health facility, wanted pregnancy, agreement to follow post-natal care, problem faced during delivery, birth order, preference of health professional for ante-natal care and maternity care were predictors of institutional delivery. The use of institutional delivery service is low in the study community. Eventhough antenatal care service is high; nearly two in every three mothers delivered their index child out of health facility. Improving socio-economic status of mothers as well as availing modern health facilities to the nearest locality will have a good impact to improve institutional delivery service utilization. Similarly, education is also a tool to improve awareness of mothers and their husbands for the improvement of health care service utilization.

Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel

PubMed Central

Black, Robert E; Taylor, Carl E; Arole, Shobha; Bang, Abhay; Bhutta, Zulfiqar A; Chowdhury, A Mushtaque R; Kirkwood, Betty R; Kureshy, Nazo; Lanata, Claudio F; Phillips, James F; Taylor, Mary; Victora, Cesar G; Zhu, Zonghan; Perry, Henry B

2017-01-01

Background The contributions that community–based primary health care (CBPHC) and engaging with communities as valued partners can make to the improvement of maternal, neonatal and child health (MNCH) is not widely appreciated. This unfortunate reality is one of the reasons why so few priority countries failed to achieve the health–related Millennium Development Goals by 2015. This article provides a summary of a series of articles about the effectiveness of CBPHC in improving MNCH and offers recommendations from an Expert Panel for strengthening CBPHC that were formulated in 2008 and have been updated on the basis of more recent evidence. Methods An Expert Panel convened to guide the review of the effectiveness of community–based primary health care (CBPHC). The Expert Panel met in 2008 in New York City with senior UNICEF staff. In 2016, following the completion of the review, the Panel considered the review’s findings and made recommendations. The review consisted of an analysis of 661 unique reports, including 583 peer–reviewed journal articles, 12 books/monographs, 4 book chapters, and 72 reports from the gray literature. The analysis consisted of 700 assessments since 39 were analyzed twice (once for an assessment of improvements in neonatal and/or child health and once for an assessment in maternal health). Results The Expert Panel recommends that CBPHC should be a priority for strengthening health systems, accelerating progress in achieving universal health coverage, and ending preventable child and maternal deaths. The Panel also recommends that expenditures for CBPHC be monitored against expenditures for primary health care facilities and hospitals and reflect the importance of CBPHC for averting mortality. Governments, government health programs, and NGOs should develop health systems that respect and value communities as full partners and work collaboratively with them in building and strengthening CBPHC programs – through engagement with planning, implementation (including the full use of community–level workers), and evaluation. CBPHC programs need to reach every community and household in order to achieve universal coverage of key evidence–based interventions that can be implemented in the community outside of health facilities and assure that those most in need are reached. Conclusions Stronger CBPHC programs that foster community engagement/empowerment with the implementation of evidence–based interventions will be essential for achieving universal coverage of health services by 2030 (as called for by the Sustainable Development Goals recently adopted by the United Nations), ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization, UNICEF, and many countries around the world), and eventually achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978. Stronger CBPHC programs can also create entry points and synergies for expanding the coverage of family planning services as well as for accelerating progress in the detection and treatment of HIV/AIDS, tuberculosis, malaria, hypertension, and other chronic diseases. Continued strengthening of CBPHC programs based on rigorous ongoing operations research and evaluation will be required, and this evidence will be needed to guide national and international policies and programs. PMID:28685046

Maternal-related deaths and impoverishment among adolescent girls in India and Niger: findings from a modelling study.

PubMed

Verguet, Stéphane; Nandi, Arindam; Filippi, Véronique; Bundy, Donald A P

2016-09-26

High levels of maternal mortality and large associated inequalities exist in low-income and middle-income countries. Adolescent pregnancies remain common, and pregnant adolescent women face elevated risks of maternal mortality and poverty. We examined the distribution across socioeconomic groups of maternal deaths and impoverishment among adolescent girls (15-19 years old) in Niger, which has the highest total fertility rate globally, and India, which has the largest number of maternal deaths. In Niger and India, among adolescent girls, we estimated the distribution per income quintile of: the number of maternal deaths; and the impoverishment, measured by calculating the number of cases of catastrophic health expenditure incurred, caused by complicated pregnancies. We also examined the potential impact on maternal deaths and poverty of increasing adolescent girls' level of education by 1 year. We used epidemiological and cost inputs sourced from surveys and the literature. The number of maternal deaths would be larger among the poorer adolescents than among the richer adolescents in Niger and India. Impoverishment would largely incur among the richer adolescents in Niger and among the poorer adolescents in India. Increasing educational attainment of adolescent girls might avert both a large number of maternal deaths and a significant number of cases of catastrophic health expenditure in the 2 countries. Adolescent pregnancies can lead to large equity gaps and substantial impoverishment in low-income and middle-income countries. Increasing female education can reduce such inequalities and provide financial risk protection and poverty alleviation to adolescent girls. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Women's education level, maternal health facilities, abortion legislation and maternal deaths: a natural experiment in Chile from 1957 to 2007.

PubMed

Koch, Elard; Thorp, John; Bravo, Miguel; Gatica, Sebastián; Romero, Camila X; Aguilera, Hernán; Ahlers, Ivonne

2012-01-01

The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs). Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957-2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques. During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (-13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (-1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (-69.2%). The slope of the MMR did not appear to be altered by the change in abortion law. Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011.

PubMed

Ntambue, Abel Mukengeshayi; Malonga, Françoise Kaj; Cowgill, Karen D; Dramaix-Wilmet, Michèle; Donnen, Philippe

2017-01-19

While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi. This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards. The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one. In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities. Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.

Using benchmarking techniques and the 2011 maternity practices infant nutrition and care (mPINC) survey to improve performance among peer groups across the United States.

PubMed

Edwards, Roger A; Dee, Deborah; Umer, Amna; Perrine, Cria G; Shealy, Katherine R; Grummer-Strawn, Laurence M

2014-02-01

A substantial proportion of US maternity care facilities engage in practices that are not evidence-based and that interfere with breastfeeding. The CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) showed significant variation in maternity practices among US states. The purpose of this article is to use benchmarking techniques to identify states within relevant peer groups that were top performers on mPINC survey indicators related to breastfeeding support. We used 11 indicators of breastfeeding-related maternity care from the 2011 mPINC survey and benchmarking techniques to organize and compare hospital-based maternity practices across the 50 states and Washington, DC. We created peer categories for benchmarking first by region (grouping states by West, Midwest, South, and Northeast) and then by size (grouping states by the number of maternity facilities and dividing each region into approximately equal halves based on the number of facilities). Thirty-four states had scores high enough to serve as benchmarks, and 32 states had scores low enough to reflect the lowest score gap from the benchmark on at least 1 indicator. No state served as the benchmark on more than 5 indicators and no state was furthest from the benchmark on more than 7 indicators. The small peer group benchmarks in the South, West, and Midwest were better than the large peer group benchmarks on 91%, 82%, and 36% of the indicators, respectively. In the West large, the Midwest large, the Midwest small, and the South large peer groups, 4-6 benchmarks showed that less than 50% of hospitals have ideal practice in all states. The evaluation presents benchmarks for peer group state comparisons that provide potential and feasible targets for improvement.

Infant mortality and family welfare: policy implications for Indonesia.

PubMed

Poerwanto, S; Stevenson, M; de Klerk, N

2003-07-01

To examine the effect of family welfare index (FWI) and maternal education on the probability of infant death. A population based multistage stratified clustered survey. Women of reproductive age in Indonesia between 1983-1997. The 1997 Indonesian Demographic and Health Survey. Infant mortality was associated with FWI and maternal education. Relative to families of high FWI, the risk of infant death was almost twice among families of low FWI (aOR=1.7, 95%CI=0.9 to 3.3), and three times for families of medium FWI (aOR=3.3,95%CI=1.7 to 6.5). Also, the risk of infant death was threefold higher (aOR=3.4, 95% CI=1.6 to 7.1) among mothers who had fewer than seven years of formal education compared with mothers with more than seven years of education. Fertility related indicators such as young maternal age, absence from contraception, birth intervals, and prenatal care, seem to exert significant effect on the increased probability of infant death. The increased probability of infant mortality attributable to family income inequality and low maternal education seems to work through pathways of material deprivation and chronic psychological stress that affect a person's health damaging behaviours. The policies that are likely to significantly reduce the family's socioeconomic inequality in infant mortality are implicated.

The value of customised centiles in assessing perinatal mortality risk associated with parity and maternal size.

PubMed

Gardosi, J; Clausson, B; Francis, A

2009-09-01

We wanted to compare customised and population standards for defining smallness for gestational age (SGA) in the assessment of perinatal mortality risk associated with parity and maternal size. Population-based cohort study. Sweden. Swedish Birth Registry database 1992-1995 with 354 205 complete records. Coefficients were derived and applied to determine SGA by the fully customised method, or by adjustment for fetal sex only, and using the same fetal weight standard. Perinatal deaths and rates of small for gestational age (SGA) babies within subgroups stratified by parity, body mass index (BMI) and maternal size within the BMI range of 20.0-24.9. Perinatal mortality rates (PMR) had a U-shaped distribution in parity groups, increased proportionately with maternal BMI, and had no association with maternal size within the normal BMI range. For each of these subgroups, SGA rates determined by the customised method showed strong association with the PMR. In contrast, SGA based on uncustomised, population-based centiles had poor correlation with perinatal mortality. The increased perinatal mortality risk in pregnancies of obese mothers was associated with an increased risk of SGA using customised centiles, and a decreased risk of SGA using population-based centiles. The use of customised centiles to determine SGA improves the identification of pregnancies which are at increased risk of perinatal death.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

PubMed

Kassebaum, Nicholas J; Bertozzi-Villa, Amelia; Coggeshall, Megan S; Shackelford, Katya A; Steiner, Caitlyn; Heuton, Kyle R; Gonzalez-Medina, Diego; Barber, Ryan; Huynh, Chantal; Dicker, Daniel; Templin, Tara; Wolock, Timothy M; Ozgoren, Ayse Abbasoglu; Abd-Allah, Foad; Abera, Semaw Ferede; Abubakar, Ibrahim; Achoki, Tom; Adelekan, Ademola; Ademi, Zanfina; Adou, Arsène Kouablan; Adsuar, José C; Agardh, Emilie E; Akena, Dickens; Alasfoor, Deena; Alemu, Zewdie Aderaw; Alfonso-Cristancho, Rafael; Alhabib, Samia; Ali, Raghib; Al Kahbouri, Mazin J; Alla, François; Allen, Peter J; AlMazroa, Mohammad A; Alsharif, Ubai; Alvarez, Elena; Alvis-Guzmán, Nelson; Amankwaa, Adansi A; Amare, Azmeraw T; Amini, Hassan; Ammar, Walid; Antonio, Carl A T; Anwari, Palwasha; Arnlöv, Johan; Arsenijevic, Valentina S Arsic; Artaman, Ali; Asad, Majed Masoud; Asghar, Rana J; Assadi, Reza; Atkins, Lydia S; Badawi, Alaa; Balakrishnan, Kalpana; Basu, Arindam; Basu, Sanjay; Beardsley, Justin; Bedi, Neeraj; Bekele, Tolesa; Bell, Michelle L; Bernabe, Eduardo; Beyene, Tariku J; Bhutta, Zulfiqar; Bin Abdulhak, Aref; Blore, Jed D; Basara, Berrak Bora; Bose, Dipan; Breitborde, Nicholas; Cárdenas, Rosario; Castañeda-Orjuela, Carlos A; Castro, Ruben Estanislao; Catalá-López, Ferrán; Cavlin, Alanur; Chang, Jung-Chen; Che, Xuan; Christophi, Costas A; Chugh, Sumeet S; Cirillo, Massimo; Colquhoun, Samantha M; Cooper, Leslie Trumbull; Cooper, Cyrus; da Costa Leite, Iuri; Dandona, Lalit; Dandona, Rakhi; Davis, Adrian; Dayama, Anand; Degenhardt, Louisa; De Leo, Diego; del Pozo-Cruz, Borja; Deribe, Kebede; Dessalegn, Muluken; deVeber, Gabrielle A; Dharmaratne, Samath D; Dilmen, Uğur; Ding, Eric L; Dorrington, Rob E; Driscoll, Tim R; Ermakov, Sergei Petrovich; Esteghamati, Alireza; Faraon, Emerito Jose A; Farzadfar, Farshad; Felicio, Manuela Mendonca; Fereshtehnejad, Seyed-Mohammad; de Lima, Graça Maria Ferreira; Forouzanfar, Mohammad H; França, Elisabeth B; Gaffikin, Lynne; Gambashidze, Ketevan; Gankpé, Fortuné Gbètoho; Garcia, Ana C; Geleijnse, Johanna M; Gibney, Katherine B; Giroud, Maurice; Glaser, Elizabeth L; Goginashvili, Ketevan; Gona, Philimon; González-Castell, Dinorah; Goto, Atsushi; Gouda, Hebe N; Gugnani, Harish Chander; Gupta, Rahul; Gupta, Rajeev; Hafezi-Nejad, Nima; Hamadeh, Randah Ribhi; Hammami, Mouhanad; Hankey, Graeme J; Harb, Hilda L; Havmoeller, Rasmus; Hay, Simon I; Pi, Ileana B Heredia; Hoek, Hans W; Hosgood, H Dean; Hoy, Damian G; Husseini, Abdullatif; Idrisov, Bulat T; Innos, Kaire; Inoue, Manami; Jacobsen, Kathryn H; Jahangir, Eiman; Jee, Sun Ha; Jensen, Paul N; Jha, Vivekanand; Jiang, Guohong; Jonas, Jost B; Juel, Knud; Kabagambe, Edmond Kato; Kan, Haidong; Karam, Nadim E; Karch, André; Karema, Corine Kakizi; Kaul, Anil; Kawakami, Norito; Kazanjan, Konstantin; Kazi, Dhruv S; Kemp, Andrew H; Kengne, Andre Pascal; Kereselidze, Maia; Khader, Yousef Saleh; Khalifa, Shams Eldin Ali Hassan; Khan, Ejaz Ahmed; Khang, Young-Ho; Knibbs, Luke; Kokubo, Yoshihiro; Kosen, Soewarta; Defo, Barthelemy Kuate; Kulkarni, Chanda; Kulkarni, Veena S; Kumar, G Anil; Kumar, Kaushalendra; Kumar, Ravi B; Kwan, Gene; Lai, Taavi; Lalloo, Ratilal; Lam, Hilton; Lansingh, Van C; Larsson, Anders; Lee, Jong-Tae; Leigh, James; Leinsalu, Mall; Leung, Ricky; Li, Xiaohong; Li, Yichong; Li, Yongmei; Liang, Juan; Liang, Xiaofeng; Lim, Stephen S; Lin, Hsien-Ho; Lipshultz, Steven E; Liu, Shiwei; Liu, Yang; Lloyd, Belinda K; London, Stephanie J; Lotufo, Paulo A; Ma, Jixiang; Ma, Stefan; Machado, Vasco Manuel Pedro; Mainoo, Nana Kwaku; Majdan, Marek; Mapoma, Christopher Chabila; Marcenes, Wagner; Marzan, Melvin Barrientos; Mason-Jones, Amanda J; Mehndiratta, Man Mohan; Mejia-Rodriguez, Fabiola; Memish, Ziad A; Mendoza, Walter; Miller, Ted R; Mills, Edward J; Mokdad, Ali H; Mola, Glen Liddell; Monasta, Lorenzo; de la Cruz Monis, Jonathan; Hernandez, Julio Cesar Montañez; Moore, Ami R; Moradi-Lakeh, Maziar; Mori, Rintaro; Mueller, Ulrich O; Mukaigawara, Mitsuru; Naheed, Aliya; Naidoo, Kovin S; Nand, Devina; Nangia, Vinay; Nash, Denis; Nejjari, Chakib; Nelson, Robert G; Neupane, Sudan Prasad; Newton, Charles R; Ng, Marie; Nieuwenhuijsen, Mark J; Nisar, Muhammad Imran; Nolte, Sandra; Norheim, Ole F; Nyakarahuka, Luke; Oh, In-Hwan; Ohkubo, Takayoshi; Olusanya, Bolajoko O; Omer, Saad B; Opio, John Nelson; Orisakwe, Orish Ebere; Pandian, Jeyaraj D; Papachristou, Christina; Park, Jae-Hyun; Caicedo, Angel J Paternina; Patten, Scott B; Paul, Vinod K; Pavlin, Boris Igor; Pearce, Neil; Pereira, David M; Pesudovs, Konrad; Petzold, Max; Poenaru, Dan; Polanczyk, Guilherme V; Polinder, Suzanne; Pope, Dan; Pourmalek, Farshad; Qato, Dima; Quistberg, D Alex; Rafay, Anwar; Rahimi, Kazem; Rahimi-Movaghar, Vafa; ur Rahman, Sajjad; Raju, Murugesan; Rana, Saleem M; Refaat, Amany; Ronfani, Luca; Roy, Nobhojit; Pimienta, Tania Georgina Sánchez; Sahraian, Mohammad Ali; Salomon, Joshua A; Sampson, Uchechukwu; Santos, Itamar S; Sawhney, Monika; Sayinzoga, Felix; Schneider, Ione J C; Schumacher, Austin; Schwebel, David C; Seedat, Soraya; Sepanlou, Sadaf G; Servan-Mori, Edson E; Shakh-Nazarova, Marina; Sheikhbahaei, Sara; Shibuya, Kenji; Shin, Hwashin Hyun; Shiue, Ivy; Sigfusdottir, Inga Dora; Silberberg, Donald H; Silva, Andrea P; Singh, Jasvinder A; Skirbekk, Vegard; Sliwa, Karen; Soshnikov, Sergey S; Sposato, Luciano A; Sreeramareddy, Chandrashekhar T; Stroumpoulis, Konstantinos; Sturua, Lela; Sykes, Bryan L; Tabb, Karen M; Talongwa, Roberto Tchio; Tan, Feng; Teixeira, Carolina Maria; Tenkorang, Eric Yeboah; Terkawi, Abdullah Sulieman; Thorne-Lyman, Andrew L; Tirschwell, David L; Towbin, Jeffrey A; Tran, Bach X; Tsilimbaris, Miltiadis; Uchendu, Uche S; Ukwaja, Kingsley N; Undurraga, Eduardo A; Uzun, Selen Begüm; Vallely, Andrew J; van Gool, Coen H; Vasankari, Tommi J; Vavilala, Monica S; Venketasubramanian, N; Villalpando, Salvador; Violante, Francesco S; Vlassov, Vasiliy Victorovich; Vos, Theo; Waller, Stephen; Wang, Haidong; Wang, Linhong; Wang, XiaoRong; Wang, Yanping; Weichenthal, Scott; Weiderpass, Elisabete; Weintraub, Robert G; Westerman, Ronny; Wilkinson, James D; Woldeyohannes, Solomon Meseret; Wong, John Q; Wordofa, Muluemebet Abera; Xu, Gelin; Yang, Yang C; Yano, Yuichiro; Yentur, Gokalp Kadri; Yip, Paul; Yonemoto, Naohiro; Yoon, Seok-Jun; Younis, Mustafa Z; Yu, Chuanhua; Jin, Kim Yun; El Sayed Zaki, Maysaa; Zhao, Yong; Zheng, Yingfeng; Zhou, Maigeng; Zhu, Jun; Zou, Xiao Nong; Lopez, Alan D; Naghavi, Mohsen; Murray, Christopher J L; Lozano, Rafael

2014-09-13

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

PubMed Central

Kassebaum, Nicholas J; Bertozzi-Villa, Amelia; Coggeshall, Megan S; Shackelford, Katya A; Steiner, Caitlyn; Heuton, Kyle R; Gonzalez-Medina, Diego; Barber, Ryan; Huynh, Chantal; Dicker, Daniel; Templin, Tara; Wolock, Timothy M; Ozgoren, Ayse Abbasoglu; Abd-Allah, Foad; Abera, Semaw Ferede; Abubakar, Ibrahim; Achoki, Tom; Adelekan, Ademola; Ademi, Zanfina; Adou, Arsène Kouablan; Adsuar, José C; Agardh, Emilie E; Akena, Dickens; Alasfoor, Deena; Alemu, Zewdie Aderaw; Alfonso-Cristancho, Rafael; Alhabib, Samia; Ali, Raghib; Al Kahbouri, Mazin J; Alla, François; Allen, Peter J; AlMazroa, Mohammad A; Alsharif, Ubai; Alvarez, Elena; Alvis-Guzmán, Nelson; Amankwaa, Adansi A; Amare, Azmeraw T; Amini, Hassan; Ammar, Walid; Antonio, Carl A T; Anwari, Palwasha; Ärnlöv, Johan; Arsenijevic, Valentina S Arsic; Artaman, Ali; Asad, Majed Masoud; Asghar, Rana J; Assadi, Reza; Atkins, Lydia S; Badawi, Alaa; Balakrishnan, Kalpana; Basu, Arindam; Basu, Sanjay; Beardsley, Justin; Bedi, Neeraj; Bekele, Tolesa; Bell, Michelle L; Bernabe, Eduardo; Beyene, Tariku J; Bhutta, Zulfiqar; Abdulhak, Aref Bin; Blore, Jed D; Basara, Berrak Bora; Bose, Dipan; Breitborde, Nicholas; Cárdenas, Rosario; Castañeda-Orjuela, Carlos A; Castro, Ruben Estanislao; Catalá-López, Ferrán; Cavlin, Alanur; Chang, Jung-Chen; Che, Xuan; Christophi, Costas A; Chugh, Sumeet S; Cirillo, Massimo; Colquhoun, Samantha M; Cooper, Leslie Trumbull; Cooper, Cyrus; da Costa Leite, Iuri; Dandona, Lalit; Dandona, Rakhi; Davis, Adrian; Dayama, Anand; Degenhardt, Louisa; De Leo, Diego; del Pozo-Cruz, Borja; Deribe, Kebede; Dessalegn, Muluken; deVeber, Gabrielle A; Dharmaratne, Samath D; Dilmen, Uğur; Ding, Eric L; Dorrington, Rob E; Driscoll, Tim R; Ermakov, Sergei Petrovich; Esteghamati, Alireza; Faraon, Emerito Jose A; Farzadfar, Farshad; Felicio, Manuela Mendonca; Fereshtehnejad, Seyed-Mohammad; de Lima, Graça Maria Ferreira; Forouzanfar, Mohammad H; França, Elisabeth B; Gaffikin, Lynne; Gambashidze, Ketevan; Gankpé, Fortuné Gbètoho; Garcia, Ana C; Geleijnse, Johanna M; Gibney, Katherine B; Giroud, Maurice; Glaser, Elizabeth L; Goginashvili, Ketevan; Gona, Philimon; González-Castell, Dinorah; Goto, Atsushi; Gouda, Hebe N; Gugnani, Harish Chander; Gupta, Rahul; Gupta, Rajeev; Hafezi-Nejad, Nima; Hamadeh, Randah Ribhi; Hammami, Mouhanad; Hankey, Graeme J; Harb, Hilda L; Havmoeller, Rasmus; Hay, Simon I; Heredia Pi, Ileana B; Hoek, Hans W; Hosgood, H Dean; Hoy, Damian G; Husseini, Abdullatif; Idrisov, Bulat T; Innos, Kaire; Inoue, Manami; Jacobsen, Kathryn H; Jahangir, Eiman; Jee, Sun Ha; Jensen, Paul N; Jha, Vivekanand; Jiang, Guohong; Jonas, Jost B; Juel, Knud; Kabagambe, Edmond Kato; Kan, Haidong; Karam, Nadim E; Karch, André; Karema, Corine Kakizi; Kaul, Anil; Kawakami, Norito; Kazanjan, Konstantin; Kazi, Dhruv S; Kemp, Andrew H; Kengne, Andre Pascal; Kereselidze, Maia; Khader, Yousef Saleh; Khalifa, Shams Eldin Ali Hassan; Khan, Ejaz Ahmed; Khang, Young-Ho; Knibbs, Luke; Kokubo, Yoshihiro; Kosen, Soewarta; Defo, Barthelemy Kuate; Kulkarni, Chanda; Kulkarni, Veena S; Kumar, G Anil; Kumar, Kaushalendra; Kumar, Ravi B; Kwan, Gene; Lai, Taavi; Lalloo, Ratilal; Lam, Hilton; Lansingh, Van C; Larsson, Anders; Lee, Jong-Tae; Leigh, James; Leinsalu, Mall; Leung, Ricky; Li, Xiaohong; Li, Yichong; Li, Yongmei; Liang, Juan; Liang, Xiaofeng; Lim, Stephen S; Lin, Hsien-Ho; Lipshultz, Steven E; Liu, Shiwei; Liu, Yang; Lloyd, Belinda K; London, Stephanie J; Lotufo, Paulo A; Ma, Jixiang; Ma, Stefan; Machado, Vasco Manuel Pedro; Mainoo, Nana Kwaku; Majdan, Marek; Mapoma, Christopher Chabila; Marcenes, Wagner; Marzan, Melvin Barrientos; Mason-Jones, Amanda J; Mehndiratta, Man Mohan; Mejia-Rodriguez, Fabiola; Memish, Ziad A; Mendoza, Walter; Miller, Ted R; Mills, Edward J; Mokdad, Ali H; Mola, Glen Liddell; Monasta, Lorenzo; de la Cruz Monis, Jonathan; Hernandez, Julio Cesar Montañez; Moore, Ami R; Moradi-Lakeh, Maziar; Mori, Rintaro; Mueller, Ulrich O; Mukaigawara, Mitsuru; Naheed, Aliya; Naidoo, Kovin S; Nand, Devina; Nangia, Vinay; Nash, Denis; Nejjari, Chakib; Nelson, Robert G; Neupane, Sudan Prasad; Newton, Charles R; Ng, Marie; Nieuwenhuijsen, Mark J; Nisar, Muhammad Imran; Nolte, Sandra; Norheim, Ole F; Nyakarahuka, Luke; Oh, In-Hwan; Ohkubo, Takayoshi; Olusanya, Bolajoko O; Omer, Saad B; Opio, John Nelson; Orisakwe, Orish Ebere; Pandian, Jeyaraj D; Papachristou, Christina; Park, Jae-Hyun; Caicedo, Angel J Paternina; Patten, Scott B; Paul, Vinod K; Pavlin, Boris Igor; Pearce, Neil; Pereira, David M; Pesudovs, Konrad; Petzold, Max; Poenaru, Dan; Polanczyk, Guilherme V; Polinder, Suzanne; Pope, Dan; Pourmalek, Farshad; Qato, Dima; Quistberg, D Alex; Rafay, Anwar; Rahimi, Kazem; Rahimi-Movaghar, Vafa; Rahman, Sajjad ur; Raju, Murugesan; Rana, Saleem M; Refaat, Amany; Ronfani, Luca; Roy, Nobhojit; Sánchez Pimienta, Tania Georgina; Sahraian, Mohammad Ali; Salomon, Joshua A; Sampson, Uchechukwu; Santos, Itamar S; Sawhney, Monika; Sayinzoga, Felix; Schneider, Ione J C; Schumacher, Austin; Schwebel, David C; Seedat, Soraya; Sepanlou, Sadaf G; Servan-Mori, Edson E; Shakh-Nazarova, Marina; Sheikhbahaei, Sara; Shibuya, Kenji; Shin, Hwashin Hyun; Shiue, Ivy; Sigfusdottir, Inga Dora; Silberberg, Donald H; Silva, Andrea P; Singh, Jasvinder A; Skirbekk, Vegard; Sliwa, Karen; Soshnikov, Sergey S; Sposato, Luciano A; Sreeramareddy, Chandrashekhar T; Stroumpoulis, Konstantinos; Sturua, Lela; Sykes, Bryan L; Tabb, Karen M; Talongwa, Roberto Tchio; Tan, Feng; Teixeira, Carolina Maria; Tenkorang, Eric Yeboah; Terkawi, Abdullah Sulieman; Thorne-Lyman, Andrew L; Tirschwell, David L; Towbin, Jeffrey A; Tran, Bach X; Tsilimbaris, Miltiadis; Uchendu, Uche S; Ukwaja, Kingsley N; Undurraga, Eduardo A; Uzun, Selen Begüm; Vallely, Andrew J; van Gool, Coen H; Vasankari, Tommi J; Vavilala, Monica S; Venketasubramanian, N; Villalpando, Salvador; Violante, Francesco S; Vlassov, Vasiliy Victorovich; Vos, Theo; Waller, Stephen; Wang, Haidong; Wang, Linhong; Wang, XiaoRong; Wang, Yanping; Weichenthal, Scott; Weiderpass, Elisabete; Weintraub, Robert G; Westerman, Ronny; Wilkinson, James D; Woldeyohannes, Solomon Meseret; Wong, John Q; Wordofa, Muluemebet Abera; Xu, Gelin; Yang, Yang C; Yano, Yuichiro; Yentur, Gokalp Kadri; Yip, Paul; Yonemoto, Naohiro; Yoon, Seok-Jun; Younis, Mustafa Z; Yu, Chuanhua; Jin, Kim Yun; El SayedZaki, Maysaa; Zhao, Yong; Zheng, Yingfeng; Zhou, Maigeng; Zhu, Jun; Zou, Xiao Nong; Lopez, Alan D; Naghavi, Mohsen; Murray, Christopher J L; Lozano, Rafael

2014-01-01

Summary Background The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100 000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. Methods We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990–2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. Findings 292 982 (95% UI 261 017–327 792) maternal deaths occurred in 2013, compared with 376 034 (343 483–407 574) in 1990. The global annual rate of change in the MMR was −0·3% (−1·1 to 0·6) from 1990 to 2003, and −2·7% (−3·9 to −1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290–2866) maternal deaths were related to HIV in 2013, 0·4% (0·2–0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1–1262·8) in South Sudan to 2·4 (1·6–3·6) in Iceland. Interpretation Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. Funding Bill & Melinda Gates Foundation. PMID:24797575

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized

PubMed Central

Melese, Tadele; Habte, Dereje; Tsima, Billy M.; Mogobe, Keitshokile Dintle; Chabaesele, Kesegofetse; Rankgoane, Goabaone; Keakabetse, Tshiamo R.; Masweu, Mabole; Mokotedi, Mosidi; Motana, Mpho; Moreri-Ntshabele, Badani

2017-01-01

Background Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. Methods A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients’ records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. Result A total of 619 patients’ records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). Conclusion Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications. PMID:28060817

Lessons from 150 years of UK maternal hemorrhage deaths.

PubMed

Kerr, Robert Stuart; Weeks, Andrew David

2015-06-01

We have reviewed maternal hemorrhage death rates in the UK over the past 150 years in order to draw lessons from this material for current attempts to reduce global maternal mortality. Mortality rates from data in the UK Annual Reports from the Registrar General were entered into a database. Charts were created to display trends in hemorrhage mortality, allowing comparison with historical medical advances. Hemorrhage death rates fell steadily before the 1930s; between 1874 and 1926 they fell by 56%. In contrast, there was no consistent reduction in overall maternal mortality rates until the 1930s; from 1932 to 1952 they fell by 85%, primarily due to a reduction in sepsis deaths. In conclusion the majority of maternal hemorrhage mortality reductions in the UK occurred prior to the availability of effective oxytocics, antibiotics, and blood transfusion. Improving access to and standards of maternal care is key to addressing global maternal mortality today. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Factors determining choice of delivery place among women of child bearing age in Dega Damot District, North West of Ethiopia: a community based cross- sectional study.

PubMed

Belay, AlemayehuSayih; Sendo, EndalewGemechu

2016-08-17

In the latest report of Ethiopia Demography and Health Survey (EDHS) 2011, the Maternal Mortality Ratio was estimated at 676/100,000 live births. Most of these deaths are preventable. Increasing the proportion of women who deliver in a health facility can be an important means in reducing maternal mortality in low-income settings including Ethiopia. We aimed to identify factors determining choice of delivery place among child bearing age women. A community based cross sectional survey was conducted in Dega Damot District from April- May, 2014. Mixed methods were employed in the study. Multistage sampling method was used. The primary outcome variable for this study was women who delivered their most recent baby in a health facility. Three hundred sixty one women who gave birth in the past 1 year were included in the study. The mean age of the respondents was 30.9 [SD ±6.006]. One hundred seven (29.6 %) of the respondents were in the age range of 25-29 years. In our study, the proportion of women assisted by skilled health workers during institutional delivery was 89.1 % followed by Health extension workers (8.0 %). Most women (87.4 %) who did not deliver in health facilities were assisted by families, friends or neighbors followed by Health extension workers (7.2 %), and traditional birth attendants (5.4 %), respectively. The qualitative data has described and gave an insight of the contributing factors that influence the women using the health institutions for delivery. These included: ANC attendance, Positive attitude of Health workers and complications during labor and delivery. The preference for a health facility delivery was largely due to the understanding that if complications occurred either during labor or delivery, this was the only place where they could be managed. The study revealed that women's institutional delivery service utilization in the study area is low. Based on these findings, improving the utilization of health facility for delivery through educating women and health promotion have been recommended. This would help reduce the complications and dangers that often characterized home-based, unsupervised delivery.

Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya.

PubMed

Bellows, Ben; Kyobutungi, Catherine; Mutua, Martin Kavao; Warren, Charlotte; Ezeh, Alex

2013-03-01

To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements. Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004-05 and 2006-08. Odds of facility-based delivery were estimated before and after introduction of an output-based voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003-10) and vaccination coverage (2003-09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006-10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother's place of delivery, NUHDSS-MCH recorded the use of the voucher. There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12-23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the voucher programme. A positive association was observed between vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations.

Extreme umbilical cord lengths, cord knot and entanglement: Risk factors and risk of adverse outcomes, a population-based study

PubMed Central

Kessler, Jörg

2018-01-01

Objectives To determine risk factors for short and long umbilical cord, entanglement and knot. Explore their associated risks of adverse maternal and perinatal outcome, including risk of recurrence in a subsequent pregnancy. To provide population based gestational age and sex and parity specific reference ranges for cord length. Design Population based registry study. Setting Medical Birth Registry of Norway 1999–2013. Population All singleton births (gestational age>22weeks<45 weeks) (n = 856 300). Methods Descriptive statistics and odds ratios of risk factors for extreme cord length and adverse outcomes based on logistic regression adjusted for confounders. Main outcome measures Short or long cord (<10th or >90th percentile), cord knot and entanglement, adverse pregnancy outcomes including perinatal and intrauterine death. Results Increasing parity, maternal height and body mass index, and diabetes were associated with increased risk of a long cord. Large placental and birth weight, and fetal male sex were factors for a long cord, which again was associated with a doubled risk of intrauterine and perinatal death, and increased risk of adverse neonatal outcome. Anomalous cord insertion, female sex, and a small placenta were associated with a short cord, which was associated with increased risk of fetal malformations, placental complications, caesarean delivery, non-cephalic presentation, perinatal and intrauterine death. At term, cord knot was associated with a quadrupled risk of perinatal death. The combination of a cord knot and entanglement had a more than additive effect to the association to perinatal death. There was a more than doubled risk of recurrence of a long or short cord, knot and entanglement in a subsequent pregnancy of the same woman. Conclusion Cord length is influenced both by maternal and fetal factors, and there is increased risk of recurrence. Extreme cord length, entanglement and cord knot are associated with increased risk of adverse outcomes including perinatal death. We provide population based reference ranges for umbilical cord length. PMID:29584790

Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan.

PubMed

Rahmani, Ahmad Masoud; Wade, Benjamin; Riley, William

2015-01-01

This study aimed to assess the potential impact a proposed family planning model would have on reducing maternal and infant mortality in Afghanistan. Afghanistan has a high total fertility rate, high infant mortality rate, and high maternal mortality rate. Afghanistan also has tremendous socio-cultural barriers to and misconceptions about family planning services. We applied predictive statistical models to a proposed family planning model for Afghanistan to better understand the impact increased family planning can have on Afghanistan's maternal mortality rate and infant mortality rate. We further developed a sensitivity analysis that illustrates the number of maternal and infant deaths that can be averted over 5 years according to different increases in contraceptive prevalence rates. Incrementally increasing contraceptive prevalence rates in Afghanistan from 10% to 60% over the course of 5 years could prevent 11,653 maternal deaths and 317,084 infant deaths, a total of 328,737 maternal and infant deaths averted. Achieving goals in reducing maternal and infant mortality rates in Afghanistan requires a culturally relevant approach to family planning that will be supported by the population. The family planning model for Afghanistan presents such a solution and holds the potential to prevent hundreds of thousands of deaths. Copyright © 2013 John Wiley & Sons, Ltd.

Impact of Training of Traditional Birth Attendants on Maternal Health Care: A Community-based Study.

PubMed

Satishchandra, D M; Naik, V A; Wantamutte, A S; Mallapur, M D; Sangolli, H N

2013-12-01

To study the impact of Training of Traditional Birth Attendants (TBAs) on maternal health care in a rural area. An interventional study in the Primary Health Center area was conducted over 1-year period between March 2006 and February 2007, which included all the 50 Traditional Birth Attendants (30 previously trained and 20 untrained), as study participants. Pretest evaluation regarding knowledge, attitude, and practices about maternal care was done. Post-test evaluation was done at the first month (early) and at the fifth month (late) after the training. Analysis was done by using Mc. Nemer's test, Chi-square test with Yates's correction and Fischer's exact test. Early and late post-test evaluation showed that there was a progressive improvement in the maternal health care provided by both the groups. Significant reduction in the maternal and perinatal deaths among the deliveries conducted by TBAs after the training was noted. Training programme for TBAs with regular follow-ups in the resource-poor setting will not only improve the quality of maternal care but also reduce perinatal deaths.

Maternal Deaths From Suicide and Overdose in Colorado, 2004–2012

PubMed Central

Metz, Torri D.; Rovner, Polina; Hoffman, M. Camille; Allshouse, Amanda A.; Beckwith, Krista M.; Binswanger, Ingrid A.

2016-01-01

Objective To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) in order to identify opportunities for prevention. Methods We report a case series of pregnancy-associated deaths due to self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado. Results Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% CI 3.4, 7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0, 6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21 ± 3.3 months postpartum) with only 6 maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). While half (n=27) of the women with deaths from self-harm were noted to be taking psycho-pharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21). Conclusion Self-harm was the most common cause of pregnancy-associated mortality with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, providers, health care systems, and both governments and organizations at the community and national level may allow for a reduction in maternal deaths. PMID:27824771

Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012.

PubMed

Metz, Torri D; Rovner, Polina; Hoffman, M Camille; Allshouse, Amanda A; Beckwith, Krista M; Binswanger, Ingrid A

2016-12-01

To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) to identify opportunities for prevention. We report a case series of pregnancy-associated deaths resulting from self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care, and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado. Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% confidence interval [CI] 3.4-7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0-6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21±3.3 months postpartum) with only six maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). Although half (n=27) of the women with deaths from self-harm were noted to be taking psychopharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21). Self-harm was the most common cause of pregnancy-associated mortality, with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, health care providers, health care systems, and both governments and organizations at the community and national levels may allow for a reduction in maternal deaths.

Strengthening health facilities for maternal and newborn care: experiences from rural eastern Uganda

PubMed Central

Namazzi, Gertrude; Waiswa, Peter; Nakakeeto, Margaret; Nakibuuka, Victoria K.; Namutamba, Sarah; Najjemba, Maria; Namusaabi, Ruth; Tagoola, Abner; Nakate, Grace; Ajeani, Judith; Peterson, Stefan; Byaruhanga, Romano N.

2015-01-01

Background In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities. Objective This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme. Design This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening. Results Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs. Conclusion Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities. PMID:25843496

Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data

PubMed Central

Saxena, Deepak; Vangani, Ruchi; Mavalankar, Dileep V.; Thomsen, Sarah

2013-01-01

Background Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth. The purpose of this study was to use district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planers to monitor equity in maternal care. Methods Secondary data analyses were performed among 7,534 ever-married women who delivered since January 2004 in the District Level Household and Facility Survey (DLHS-3) carried out during 2007–2008 in Gujarat, India. Based on the conceptual framework designed by the Commission on the Social Determinants of Health, associations were assessed between three outcomes – Institutional delivery, antenatal care (ANC), and use of modern contraception – and selected intermediary and structural determinants of health using multiple logistic regression. Results Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence. Discussion and conclusions Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services. PMID:23469890

Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data.

PubMed

Saxena, Deepak; Vangani, Ruchi; Mavalankar, Dileep V; Thomsen, Sarah

2013-03-06

Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth. The purpose of this study was to use district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planers to monitor equity in maternal care. Secondary data analyses were performed among 7,534 ever-married women who delivered since January 2004 in the District Level Household and Facility Survey (DLHS-3) carried out during 2007-2008 in Gujarat, India. Based on the conceptual framework designed by the Commission on the Social Determinants of Health, associations were assessed between three outcomes - Institutional delivery, antenatal care (ANC), and use of modern contraception - and selected intermediary and structural determinants of health using multiple logistic regression. Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence. Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services.

OS033. Correlates of maternal health outcomes associated with a low-costintervention in secondary facilities across Kano state, Nigeria.

PubMed

Tukur, J; Ahonsi, B; Salisu, I; Oginni, A B; Okereke, E

2012-07-01

Nigeria has one of the highest rates of maternal mortality in the world. Eclampsia is a major contributor to the deaths especially in Northern Nigeria where the culture of teenage marriage is common. Kano is the state with the highest population in Nigeria. Despite its effectiveness, magnesium sulphate was been used to treat eclampsia and severe preclampsia in only one of 35 general hospitals inthe state as at 2007. In 2008, magnesium sulphate was introduced in 10 General Hospitals in Kano state of Northern Nigeria in a Population Council project funded by the MacArthur Foundation. The aim of the study was to determine if the maternal outcomes improved. Doctors and midwives from the 10 hospitals were trained on the use of magnesium sulphate. The trained health workers later conducted step down trainings at their health facilities. Magnesium sulphate, treatment protocol, patella hammer and calcium gluconate were then supplied to the hospitals. Data was collected through structured data forms. The data was analysed using SPSS. Within a year of the project, 1045 patients with severe preeclampsia and eclampsia were treated. The case fatality rate for severe preeclampsia and eclampsia fell from 20.9% (95% CI 18.7-23.2) recorded before the project to 2.3% (95%CI 1.5-3.5) after the project. The perinatal mortality rate in those that received magnesium sulphate was 12.3% (CI 10.4-14.5) while the 5min APGAR score for 72.9% of the babies was 7 or more. Training of health workers on updated evidence based interventions and providing an enabling environment for their practice are key components to the attainment of the Millennium Development Goals in developing countries. Copyright © 2012. Published by Elsevier B.V.

Resuscitation and Obstetrical Care to Reduce Intrapartum-Related Neonatal Deaths: A MANDATE Study.

PubMed

Kamath-Rayne, Beena D; Griffin, Jennifer B; Moran, Katelin; Jones, Bonnie; Downs, Allan; McClure, Elizabeth M; Goldenberg, Robert L; Rouse, Doris; Jobe, Alan H

2015-08-01

To evaluate the impact of neonatal resuscitation and basic obstetric care on intrapartum-related neonatal mortality in low and middle-income countries, using the mathematical model, Maternal and Neonatal Directed Assessment of Technology (MANDATE). Using MANDATE, we evaluated the impact of interventions for intrapartum-related events causing birth asphyxia (basic neonatal resuscitation, advanced neonatal care, increasing facility birth, and emergency obstetric care) when implemented in home, clinic, and hospital settings of sub-Saharan African and India for 2008. Total intrapartum-related neonatal mortality (IRNM) was acute neonatal deaths from intrapartum-related events plus late neonatal deaths from ongoing intrapartum-related injury. Introducing basic neonatal resuscitation in all settings had a large impact on decreasing IRNM. Increasing facility births and scaling up emergency obstetric care in clinics and hospitals also had a large impact on decreasing IRNM. Increasing prevalence and utilization of advanced neonatal care in hospital settings had limited impact on IRNM. The greatest improvement in IRNM was seen with widespread advanced neonatal care and basic neonatal resuscitation, scaled-up emergency obstetric care in clinics and hospitals, and increased facility deliveries, resulting in an estimated decrease in IRNM to 2.0 per 1,000 live births in India and 2.5 per 1,000 live births in sub-Saharan Africa. With more deliveries occurring in clinics and hospitals, the scale-up of obstetric care can have a greater effect than if modeled individually. Use of MANDATE enables health leaders to direct resources towards interventions that could prevent intrapartum-related deaths. A lack of widespread implementation of basic neonatal resuscitation, increased facility births, and emergency obstetric care are missed opportunities to save newborn lives.

Primary birthing attendants and birth outcomes in remote Inuit communities—a natural “experiment” in Nunavik, Canada

PubMed Central

Simonet, F; Wilkins, R; Labranche, E; Smylie, J; Heaman, M; Martens, P; Fraser, W D; Minich, K; Wu, Y; Carry, C; Luo, Z-C

2010-01-01

Background There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural “experiment”, birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities. Methods A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989–2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. Results The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at ≥28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. Conclusion Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities. PMID:19286689

[Maternal mortality in the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie for a period of 10 years].

PubMed

González-Rosales, Ricardo; Ayala-Leal, Isabel; Cerda-López, Jorge Alejandro; Cerón-Saldaña, Miguel Angel

2010-04-01

In Mexico, maternal mortality has fallen substantially in recent decades. Although according to the Secretaria de Salud, in Tamaulipas the maternal mortality rate has increased in recent years. Despite these facts, Tamaulipas ranks among the ten institutions with the lowest level of maternal mortality. To describe the basic elements of epidemiologic behavior of maternal mortality during a period of ten years at the Gynecology and Obstetrics department of the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie in Tamaulipas, Mexico. A descriptive, transverse, retrospective and a cases series research was carried out at the Gynecology and Obstetrics department of the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie in Tamaulipas, Mexico. There was a revision of the expedients of direct and indirect obstetric maternal deaths occurred from January 1, 1998 to December 31, 2007. We used descriptive statistics with central trend measurements and standard deviation. 30 obstetric maternal deaths were registered. Maternal death ratio was 87.2 x 100,000 live births during the 10 years. The average age of patients was 25.1 +/- 7.8 years old. 54% were in their first pregnancy. Only 20% had adequate prenatal control. Direct obstetric causes were 60% and indirect obstetric causes 40%. The main causes of maternal deaths were preeclampsia/eclampsia (27%), obstetric hemorrhage (20%) and gravid-puerperal sepsis (13%). 83% was foreseeable. It was noted a clear trend towards the reduction in the maternal mortality ratio in the decade from 1998 to 2007. Preeclampsia-eclampsia and obstetric hemorrhage remain the main causes of maternal death. The maternal mortality ratio tended to invest when comparing the first five years with the last five years of the study, which talks about improvements in management and direct obstetric causes prevention.

Out-of-pocket costs for facility-based maternity care in three African countries.

PubMed

Perkins, Margaret; Brazier, Ellen; Themmen, Ellen; Bassane, Brahima; Diallo, Djeneba; Mutunga, Angeline; Mwakajonga, Tuntufye; Ngobola, Olipa

2009-07-01

OBJECTIVE To estimate out-of-pocket medical expenses to women and families for maternity care at all levels of the health system in Burkina Faso, Kenya and Tanzania. METHODS In a population-based survey in 2003, 6345 women who had given birth in the previous 24 months were interviewed about the costs incurred during childbirth. Three years later, in 2006, an additional 8302 women with recent deliveries were interviewed in the same districts to explore their maternity care-seeking experiences and associated costs. The majority of women interviewed reported paying out-of-pocket costs for facility-based deliveries. Out-of-pocket costs were highest in Kenya (a mean of US$18.4 for normal and complicated deliveries), where 98% of women who delivered in a health facility had to pay some fees. In Burkina Faso, 92% of women reported paying some fees (mean of US$7.9). Costs were lowest in Tanzania, where 91% of women reported paying some fees (mean of US$5.1). In all three countries, women in the poorest wealth quintile did not pay significantly less for maternity costs than the wealthiest women. Costs for complicated delivery were double those for normal delivery in Burkina Faso and Kenya, and represented more than 16% of mean monthly household income in Burkina Faso, and 35% in Kenya. In Tanzania and Burkina Faso most institutional births were at mid-level government health facilities (health centres or dispensaries). In contrast, in Kenya, 42% of births were at government hospitals, and 28% were at private or mission facilities, contributing to the overall higher costs in this country compared with Burkina Faso and Tanzania. However, among women delivering in government health facilities in Kenya, reported out-of-pocket costs were significantly lower in 2006 than in 2003, indicating that a 2004 national policy eliminating user fees at mid- and lower-level government health facilities was having some impact.

The untold story: how the health care systems in developing countries contribute to maternal mortality.

PubMed

Sundari, T K

1992-01-01

This article attempts to put together evidence from maternal mortality studies in developing countries of how an inadequate health care system characterized by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of essential health information to the women most affected, and the physical as well as economic and sociocultural distance separating health services from the vast majority of women, are only part of the problem. Even when the woman reaches a health facility, there are a number of obstacles to her receiving adequate and appropriate care. These are a result of failures in the health services delivery system: the lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals; and worst of all, faulty patient management. Prevention of maternal deaths requires fundamental changes not only in resource allocation, but in the very structures of health services delivery. These will have to be fought for as part of a wider struggle for equity and social justice.

Where There Are (Few) Skilled Birth Attendants

PubMed Central

Prata, Ndola; Rowen, Tami; Bell, Suzanne; Walsh, Julia; Potts, Malcolm

2011-01-01

Recent efforts to reduce maternal mortality in developing countries have focused primarily on two long-term aims: training and deploying skilled birth attendants and upgrading emergency obstetric care facilities. Given the future population-level benefits, strengthening of health systems makes excellent strategic sense but it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. There are currently 28 countries from four major regions in which fewer than half of all births are attended by skilled birth attendants. Sixty-nine percent of maternal deaths in these four regions can be attributed to these 28 countries, despite the fact that these countries only constitute 34% of the total population in these regions. Trends documenting the change in the proportion of births accompanied by a skilled attendant in these 28 countries over the last 15-20 years offer no indication that adequate change is imminent. To rapidly reduce maternal mortality in regions where births in the home without skilled birth attendants are common, governments and community-based organizations could implement a cost-effective, complementary strategy involving health workers who are likely to be present when births in the home take place. Training community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) will increase the chance that women in the lowest economic quintiles will also benefit from global safe motherhood efforts. PMID:21608417

The importance of public sector health facility-level data for monitoring changes in maternal mortality risks among communities: the case of pakistan.

PubMed

Jain, Anrudh K; Sathar, Zeba; Salim, Momina; Shah, Zakir Hussain

2013-09-01

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal.

Social autopsy study identifies determinants of neonatal mortality in Doume, Nguelemendouka and Abong–Mbang health districts, Eastern Region of Cameroon

PubMed Central

Koffi, Alain K.; Libite, Paul–Roger; Moluh, Seidou; Wounang, Romain; Kalter, Henry D.

2015-01-01

Background Reducing preventable medical causes of neonatal death for faster progress toward the MGD4 will require Cameroon to adequately address the social factors contributing to these deaths. The objective of this paper is to explore the social, behavioral and health systems determinants of newborn death in Doume, Nguelemendouka and Abong–Mbang health districts, in Eastern Region of Cameroon, from 2007–2010. Methods Data come from the 2012 Verbal/Social Autopsy (VASA) study, which aimed to determine the biological causes and social, behavioral and health systems determinants of under–five deaths in Doume, Nguelemendouka and Abong–Mbang health districts in Eastern Region of Cameroon. The analysis of the data was guided by the review of the coverage of key interventions along the continuum of normal maternal and newborn care and by the description of breakdowns in the care provided for severe neonatal illnesses within the Pathway to Survival conceptual framework. Results One hundred sixty–four newborn deaths were confirmed from the VASA survey. The majority of the deceased newborns were living in households with poor socio–economic conditions. Most (60–80%) neonates were born to mothers who had one or more pregnancy or labor and delivery complications. Only 23% of the deceased newborns benefited from hygienic cord care after birth. Half received appropriate thermal care and only 6% were breastfed within one hour after birth. Sixty percent of the deaths occurred during the first day of life. Fifty–five percent of the babies were born at home. More than half of the deaths (57%) occurred at home. Of the 64 neonates born at a health facility, about 63% died in the health facility without leaving. Careseeking was delayed for several neonates who became sick after the first week of life and whose illnesses were less serious at the onset until they became more severely ill. Cost, including for transport, health care and other expenses, emerged as main barriers to formal care–seeking both for the mothers and their newborns. Conclusions This study presents an opportunity to strengthen maternal and newborn health by increasing the coverage of essential and low cost interventions that could have saved the lives of many newborns in eastern Cameroon. PMID:26171142

How Has the Free Obstetric Care Policy Impacted Unmet Obstetric Need in a Rural Health District in Guinea?

PubMed

Delamou, Alexandre; Dubourg, Dominique; Beavogui, Abdoul Habib; Delvaux, Thérèse; Kolié, Jacques Seraphin; Barry, Thierno Hamidou; Camara, Bienvenu Salim; Edginton, Mary; Hinderaker, Sven; De Brouwere, Vincent

2015-01-01

In 2010, the Ministry of Health (MoH) of Guinea introduced a free emergency obstetric care policy in all the public health facilities of the country. This included antenatal checks, normal delivery and Caesarean section. This study aims at assessing the changes in coverage of obstetric care according to the Unmet Obstetric Need concept before (2008) and after (2012) the implementation of the free emergency obstetric care policy in a rural health district in Guinea. We carried out a descriptive cross-sectional study involving the retrospective review of routine programme data during the period April to June 2014. No statistical difference was observed in women's sociodemographic characteristics and indications (absolute maternal indications versus non-absolute maternal indications) before and after the implementation of the policy. Compared to referrals from health centers of patients, direct admissions at hospital significantly increased from 49% to 66% between 2008 and 2012 (p = 0.001). In rural areas, this increase concerned all maternal complications regardless of their severity, while in urban areas it mainly affected very severe complications. Compared to 2008, there were significantly more Major Obstetric Interventions for Maternal Absolute Indications in 2012 (p < 0.001). Maternal deaths decreased between 2008 and 2012 from 1.5% to 1.1% while neonatal death increased from 12% in 2008 to 15% in 2012. The implementation of the free obstetric care policy led to a significant decrease in unmet obstetric need between 2008 and 2012 in the health district of Kissidougou. However, more research is needed to allow comparisons with other health districts in the country and to analyse the trends.

Reaching help on time in an emergency delivery.

PubMed

1991-01-01

Many maternal deaths in developing countries occur because mothers with complicated pregnancies or deliveries cannot be transported at all or fast enough to a health facility. A pregnant woman hemorrhaging greatly had to wait for a taxi because an unauthorized person had the health center's vehicle in Tanzania. Since most physicians practice in cities, most maternal deaths involve rural women. Further the less educated, lower the socioeconomic status, and lower the family's income the more likely she is to die. 3 phases contributed to transport delays of pregnant women. The 1st phase includes the time it take for a woman and her family to decide if her condition is serious enough to require medical attention, and if so, can they afford to pay for transport. Sometimes the services scare her or she considers the services to be of poor quality. The next phase involves the availability of transport and the distance between the mother and the services. Indeed in Nigeria, 96% of mothers who do not use medical delivery services report that they do not do so because of distance. Once at the health facility, the waiting period between arrival and meeting the woman's medical needs make up the 3rd phase. Often health facilities have inadequate number of medical personnel. Moreover the family must buy needed medical supplies before treatment can even begin. Alarm and transport systems are needed. In 1 area of India, pigeons carry messages to a physician that a woman is experiencing labor difficulties. Prior to the civil war in Somalia, a distinct flag informed passing motorists that emergency transport was needed for a pregnant woman who was carried to the roadside on a stretcher or in a cart. High technology transport is not cost effective and should not be part of a primary health care system.

Implementation research to improve quality of maternal and newborn health care, Malawi

PubMed Central

Wilhelm, Danielle; Lohmann, Julia; Kambala, Christabel; Chinkhumba, Jobiba; Muula, Adamson S; De Allegri, Manuela

2017-01-01

Abstract Objective To evaluate the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. Methods We conducted a non-randomized controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. We assessed changes in the facilities’ essential drug stocks, equipment maintenance and clinical obstetric care processes. Difference-in-difference regression models were used to analyse effects of the scheme on adherence to obstetric care treatment protocols and provision of essential drugs, supplies and equipment. Findings We observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. We observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants’ adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. Conclusion Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care. PMID:28670014

Continuing with “…a heavy heart” - consequences of maternal death in rural Kenya

PubMed Central

2015-01-01

Background This study analyzes the consequences of maternal death to households in Western Kenya, specifically, neonatal and infant survival, childcare and schooling, disruption of daily household activities, the emotional burden on household members, and coping mechanisms. Methods The study is a combination of qualitative analysis with matched and unmatched quantitative analysis using surveillance and survey data. Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy that led to the death; schooling experiences of surviving school-age children; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. Quantitative data on neonatal and infant survival from a demographic surveillance system in the study area were also used. Descriptive and bivariate analyses were conducted with the quantitative data, and qualitative data were analyzed through text analysis using NVivo. Results More than three-quarters of deceased women performed most household tasks when healthy. After the maternal death, the responsibility for these tasks fell primarily on the deceased’s husbands, mothers, and mothers-in-law. Two-thirds of the individuals from households that suffered a maternal death had to shift into another household. Most children had to move away, mostly to their grandmother’s home. About 37% of live births to women who died of maternal causes survived till age 1 year, compared to 65% of live births to a matched sample of women who died of non-maternal causes and 93% of live births to surviving women. Older, surviving children missed school or did not have enough time for schoolwork, because of increased housework or because the loss of household income due to the maternal death meant school fees could not be paid. Respondents expressed grief, frustration, anger and a sense of loss. Generous family and community support during the funeral and mourning periods was followed by little support thereafter. Conclusion The detrimental consequences of a maternal death ripple out from the woman’s spouse and children to the entire household, and across generations. PMID:26000827

National, regional, and global levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030: a systematic analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group

PubMed Central

Alkema, Leontine; Chou, Doris; Hogan, Daniel; Zhang, Sanqian; Moller, Ann-Beth; Gemmill, Alison; Fat, Doris Ma; Boerma, Ties; Temmerman, Marleen; Mathers, Colin; Say, Lale; Ahmed, Saifuddin; Ali, Mohamed; Amouzou, Agbessi; Braunholtz, David; Byass, Peter; Carvajal-Velez, Liliana; Gaigbe-Togbe, Victor; Gerland, Patrick; Loaiza, Edilberto; Mills, Samuel; Mutombo, Namuunda; Newby, Holly; Pullum, Thomas W.; Suzuki, Emi

2017-01-01

Summary Background Millennium Development Goal (MDG) 5 calls for a reduction of 75% in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed scenario-based projections to highlight the accelerations needed to accomplish the Sustainable Development Goal (SDG) global target of less than 70 maternal deaths per 100,000 live births globally by 2030. Methods We updated the open access UN Maternal Mortality Estimation Inter-agency Group (MMEIG) database. Based upon nationally-representative data for 171 countries, we generated estimates of maternal mortality and related indicators with uncertainty intervals using a Bayesian model, which extends and refines the previous UN MMEIG estimation approach. The model combines the rate of change implied by a multilevel regression model with a time series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. Results The global MMR declined from 385 deaths per 100,000 live births (80% uncertainty interval ranges from 359 to 427) in 1990 to 216 (207 to 249) in 2015, corresponding to a relative decline of 43.9% (34.0 to 48.7) during the 25-year period, with 303,000 (291,000 to 349,000) maternal deaths globally in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1.8% (0 to 3.1) in the Caribbean to 5.0% (4.0 to 6.0) for Eastern Asia. Regional MMRs for 2015 range from 12 (11 to 14) for developed regions to 546 (511 to 652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7.5%. Interpretation Despite global progress in reducing maternal mortality, immediate action is required to begin making progress towards the ambitious SDG 2030 target, and ultimately eliminating preventable maternal mortality. While the rates of reduction that are required to achieve country-specific SDG targets are ambitious for the great majority of high mortality countries, the experience and rates of change between 2000 and 2010 in selected countries–those with concerted efforts to reduce the MMR- provide inspiration as well as guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. Funding Funding from grant R-155-000-146-112 from the National University of Singapore supported the research by LA and SZ. AG is the recipient of a National Institute of Child Health and Human Development, grant # T32-HD007275. Funding also provided by USAID and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). PMID:26584737

Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi

PubMed Central

Koffi, Alain K.; Mleme, Tiope; Nsona, Humphreys; Banda, Benjamin; Amouzou, Agbessi; Kalter, Henry D.

2015-01-01

Background The Every Newborn Action Plan calls for reducing the neonatal mortality rates to fewer than 10 deaths per 1000 live births in all countries by 2035. The current study aims to increase our understanding of the social and modifiable factors that can be addressed or reinforced to improve and accelerate the decline in neonatal mortality in Malawi. Methods The data come from the 2013 Verbal and Social Autopsy (VASA) study that collected data in order to describe the biological causes and the social determinants of deaths of children under 5 years of age in Balaka and Salima districts of Malawi. This paper analyses the social autopsy data of the neonatal deaths and presents results of a review of the coverage of key interventions along the continuum of normal maternal and newborn care and the description of breakdowns in the care provided for neonatal illnesses within the Pathway to Survival framework. Results A total of 320 neonatal deaths were confirmed from the VASA survey. While one antenatal care (ANC) visit was high at 94%, the recommended four ANC visits was much lower at 41% and just 17% of the mothers had their urines tested during the pregnancy. 173 (54%) mothers of the deceased newborns had at least one labor/delivery complication that began at home. The caregivers of 65% (n = 75) of the 180 newborns that were born at home or born and left a health facility alive perceived them to be severely ill at the onset of their illness, yet only 44% (n = 80) attempted and 36% (n = 65)could reach the first health provider after an average of 91 minutes travel time. Distance, lack of transport and cost emerged as the most important constraints to formal care–seeking during delivery and during the newborn fatal illness. Conclusions This study suggests that maternal and neonatal health organizations and the local government of Malawi should increase the demand for key maternal and child health interventions, including the recommended 4 ANC visits, and ensure urine screening for all pregnant women. Early recognition and referrals of women with obstetric complications and interventions to promote maternal recognition of neonatal illnesses and care–seeking before the child becomes severely ill are also needed to improve newborn survival in Balaka and Salima districts of Malawi. PMID:27698997

Inequities and their determinants in coverage of maternal health services in Burkina Faso.

PubMed

Mwase, Takondwa; Brenner, Stephan; Mazalale, Jacob; Lohmann, Julia; Hamadou, Saidou; Somda, Serge M A; Ridde, Valery; De Allegri, Manuela

2018-05-11

Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.

Maternal mortality in St. Petersburg, Russian Federation.

PubMed Central

Gurina, Natalia A.; Vangen, Siri; Forsén, Lisa; Sundby, Johanne

2006-01-01

OBJECTIVE: To study the levels and causes of maternal mortality in St. Petersburg, Russian Federation. METHODS: We collected data about all pregnancy-related deaths in St. Petersburg over the period 1992-2003 using several sources of information. An independent research group reviewed and classified all cases according to ICD-10 and the Confidential Enquiries into Maternal Deaths in the United Kingdom. We tested trends of overall and cause specific ratios (deaths per 100,000 births) for four 3-year intervals using the chi2 test. FINDINGS: The maternal mortality ratio for the study period was 43 per 100,000 live births. A sharp decline of direct obstetric deaths was observed from the first to fourth 3-year interval (49.8 for 1992-94 versus 18.5 for 2001-03). Sepsis and haemorrhage were the main causes of direct obstetric deaths. Among the total deaths from sepsis, 63.8% were due to abortion. Death ratios from sepsis declined significantly from the first to second study interval. In the last study interval (2001-03), 50% of deaths due to haemorrhage were secondary to ectopic pregnancies. The death ratio from thromboembolism remained low (2.9%) and stable throughout the study period. Among indirect obstetric deaths a non-significant decrease was observed for deaths from cardiac disease. Death ratios from infectious causes and suicides increased over the study period. CONCLUSIONS: Maternal mortality levels in St. Petersburg still exceed European levels by a factor of five. Improved management of abortion, emergency care for sepsis and haemorrhage, and better identification and control of infectious diseases in pregnancy, are needed. PMID:16628301

QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali.

PubMed

Dumont, Alexandre; Fournier, Pierre; Fraser, William; Haddad, Slim; Traore, Mamadou; Diop, Idrissa; Gueye, Mouhamadou; Gaye, Alioune; Couturier, François; Pasquier, Jean-Charles; Beaudoin, François; Lalonde, André; Hatem, Marie; Abrahamowicz, Michal

2009-09-18

Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel. This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews. The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.

Effect of an innovative community based health program on maternal health service utilization in north and south central Ethiopia: a community based cross sectional study.

PubMed

Afework, Mesganaw Fantahun; Admassu, Kesteberhan; Mekonnen, Alemayehu; Hagos, Seifu; Asegid, Meselech; Ahmed, Saifuddin

2014-04-04

Among Millennium Development Goals, achieving the fifth goal (MDG-5) of reducing maternal mortality poses the greatest challenge in Sub-Saharan Africa. Ethiopia has one of the highest maternal mortality ratios in the world with unacceptably low maternal health service utilization. The Government of Ethiopia introduced an innovative community-based intervention as a national strategy under the Health Sector Development Program. This new approach, known as the Health Extension Program, aims to improve access to and equity in essential health services through community based Health Extension Workers. The objective of the study is to assess the role of Health Extension Workers in improving women's utilization of antenatal care, delivery at health facility and postnatal care services. A cross sectional household survey was conducted in early 2012 in two districts of northern and south central parts of Ethiopia. Data were collected from 4949 women who had delivered in the two years preceding the survey. Logistic regression analysis was performed to determine the association between visit by Health Extension Workers during pregnancy and use of maternal health services, controlling for the effect of other confounding factors. The non-adjusted analysis showed that antenatal care attendance at least four times during pregnancy was significantly associated with visit by Health Extension Workers [Odds Ratio 3.46(95% CI 3.07,3.91)], whereas health facility delivery (skilled attendance at birth) was not significantly associated with visit by Health Extension Workers during pregnancy [Odds Ratio 0.87(95% CI 0.25,2.96)]. When adjusted for other factors the association of HEWs visit during pregnancy was weaker for antenatal care attendance [Adjusted Odds Ratio: 1.35(95% CI: 1.05, 1.72)] but positively and significantly associated with health facility delivery [Adjusted Odds Ratio 1.96(1.25,3.06)]. In general HEWs visit during pregnancy improved utilization of maternal health services. Health facility delivery is heavily affected by other factors. Meaningful improvement in skilled attendance at birth (health facility delivery) should include addressing other factors on top of visits by HEWs during pregnancy and specific target oriented interventions during visits by HEWs to support skilled attendance at birth.

Evaluating the effect of the Helping Mothers Survive Bleeding after Birth (HMS BAB) training in Tanzania and Uganda: study protocol for a randomised controlled trial.

PubMed

Hanson, Claudia; Pembe, Andrea B; Alwy, Fadhlun; Atuhairwe, Susan; Leshabari, Sebalda; Morris, Jessica; Kaharuza, Frank; Marrone, Gaetano

2017-07-06

Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie® birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health provider's knowledge, skills and confidence, evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively, with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome, which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase, which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used, taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health provider's skills, care and interventions and health system readiness. This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial, the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. Pan African Clinical Trials Registry, PACTR201604001582128 . Registered on 12 April 2016.

Association between maternal nutritional extremes and offspring mortality: A population-based cross-sectional study, Brazil, Demographic Health Survey 2006.

PubMed

Felisbino-Mendes, Mariana Santos; Moreira, Alexandra Dias; Velasquez-Melendez, Gustavo

2015-09-01

to estimate the association between maternal nutritional extremes and offspring mortality in the Brazilian population. this cross-sectional study used secondary data from Brazilian women of reproductive age obtained from the National Demographic and Health Survey 2006. Maternal anthropometric indices were used: height, body mass index (BMI), and waist circumference. Logistic regression modelling was used to evaluate the relationship between obesity and offspring mortality. The data analysis was appropriate for the complex sample design. children of mothers of short stature were at greater risk of death in the postnatal period than children of mothers of normal height, even after adjusting for sociodemographic characteristics [odds ratio (OR) 4.54, 95% confidence interval (CI) 1.31-15.77]. Maternal obesity was associated with mortality, and children whose mothers were abdominally obese were at greater risk of dying in the neonatal period (OR 3.19, 95% CI 1.23-8.27). Children of mothers who were overweight or obese (BMI≥25kg/m(2)) were at greater risk of dying in the neonatal period (OR 2.41, 95% CI 1.12-5.16), and children of malnourished mothers (BMI<18.5kg/m(2)) were at greater risk of dying during the postneonatal period (OR 9.47, 95% CI 2.07-43.41). maternal obesity is a risk factor for neonatal death, maternal malnutrition is a risk factor for postneonatal death, and maternal short stature is a risk factor for mortality among Brazilian children. Copyright © 2015 Elsevier Ltd. All rights reserved.

The role of civil society in strengthening intercultural maternal health care in local health facilities: Puno, Peru

PubMed Central

Samuel, Jeannie

2016-01-01

Background and objective Peru's Ministry of Health has made efforts to increase the cultural inclusiveness of maternal health services. In 2005, the Ministry adopted an intercultural birthing policy (IBP) that authorizes and encourages the use of culturally acceptable birthing practices in government-run health facilities. However, studies suggest that indigenous women may receive inconsistent benefits from these kinds of policies. This article examines whether a grassroots accountability initiative based on citizen monitoring of local health facilities by indigenous women can help to promote the objectives of the IBP and improve intercultural maternal health care. Design Findings are drawn from a larger qualitative research study completed in 2015 that included fieldwork done between 2010 and 2011. Semi-structured interviews were conducted with 23 women working as citizen monitors in local health facilities in Puno and 30 key informants, including frontline health workers, health officials, and civil society actors in Puno and Lima, and human rights lawyers from the Defensoría del Pueblo Office in Puno. Results Monitors confirmed from their own personal experiences in the 1990s and early 2000s that respect for intercultural aspects of maternal health care, including traditional indigenous birthing practices, were not readily accepted in publicly funded health facilities. It was also common for indigenous women to face discrimination when seeking health service provided by the state. Although the government's adoption of the IBP in 2005 was a positive step, considerable efforts are still needed to ensure high-quality, culturally appropriate maternal health care is consistently available in local health facilities. Conclusions Despite important progress in the past two decades, policies aimed at improving intercultural maternal health care are unevenly implemented in local health facilities. Civil society, in particular indigenous women themselves, can play an important role in holding the state accountable for quality care. PMID:27987298

Homicide-Followed-by-Suicide Incidents Involving Child Victims

PubMed Central

Logan, Joseph E.; Walsh, Sabrina; Patel, Nimeshkumar; Hall, Jeffrey E.

2015-01-01

Objectives To describe homicide-followed-by-suicide incidents involving child victims Methods Using 2003–2009 National Violent Death Reporting System data, we characterized 129 incidents based on victim and perpetrator demographic information, their relationships, the weapons/mechanisms involved, and the perpetrators’ health and stress-related circumstances. Results These incidents accounted for 188 child deaths; 69% were under 11 years old, and 58% were killed with a firearm. Approximately 76% of perpetrators were males, and 75% were parents/caregivers. Eighty-one percent of incidents with paternal perpetrators and 59% with maternal perpetrators were preceded by parental discord. Fifty-two percent of incidents with maternal perpetrators were associated with maternal psychiatric problems. Conclusions Strategies that resolve parental conflicts rationally and facilitate detection and treatment of parental mental conditions might help prevention efforts. PMID:23985234

Maternal mortality in India: current status and strategies for reduction.

PubMed

Prakash, A; Swain, S; Seth, A

1991-12-01

The causes (medical, reproductive factors, health care delivery system, and socioeconomic factors) of maternal mortality in India and strategies for reducing maternal mortality are presented. Maternal mortality rates (MMR) are very high in Asia and Africa compared with Northern Europe's 4/100,000 live births. An Indian hospital study found the MMR to be 4.21/1000 live births. 50-98% of maternal deaths are caused by direct obstetric causes (hemorrhage, infection, and hypertensive disorders, ruptured uterus, hepatitis, and anemia). 50% of maternal deaths due to sepsis are related to illegal induced abortion. MMR in India has not declined significantly in the past 15 years. Age, primi and grande multiparity, unplanned pregnancy, and related illegal abortion are the reproductive causes. In 1985 WHO reported that 63-80% of maternal deaths due to direct obstetric causes and 88-98% of all maternal deaths could probably have been prevented with proper handling. In India, coordination between levels in the delivery system and fragmentation of care account for the poor quality of maternal health care. Mass illiteracy is another cause. Effective strategies for reducing the MMR are 1) to place a high priority on maternal and child health (MCH) services and integrate vertical programs (e.g., family planning) related to MCH; 2) to give attention to care during labor and delivery, which is the most critical period for complications; 3) to provide community-based delivery huts which can provide a clean and safe delivery place close to home, and maternity waiting rooms in hospitals for high risk mothers; 4) to improve the quality of MCH care at the rural community level (proper history taking, palpation, blood pressure and fetal heart screening, risk factor screening, and referral); 5) to improve quality of care at the primary health care level (emergency care and proper referral); 6) to include in the postpartum program MCH and family planning services; 7) to examine the feasibility of a national blood transfusion service network; 8) to improve transportation; 9) to educate young girls on health and sex; 10) to informally educate the masses on MCH; 11) to focus obstetrics and gynecology training primarily on practical skills in management of labor and delivery; 12) to research reproductive behavior; and 13) to assure every women the right to safe motherhood.

Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy

PubMed Central

Aradeon, Susan B; Doctor, Henry V

2016-01-01

The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support structures. Innovative communication body tools and the rote learning Rapid Imitation Practice training methodology enabled low-literate volunteers to saturate their communities with informed group discussions transferring communication capacity and ownership to the discussion participants. CCER is especially efficient because virtually every timely, community referral for emergency maternal care results in a saved life, whereas on average, only one in every eight births delivered by an SBA (12%) is expected to be a delivery-associated complication requiring lifesaving care. PMID:27088844

Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study.

PubMed

Varghese, Beena; Krishnamurthy, Jayanna; Correia, Blaze; Panigrahi, Ruchika; Washington, Maryann; Ponnuswamy, Vinotha; Mony, Prem

2016-12-23

The majority of the maternal and perinatal deaths are preventable through improved emergency obstetric and newborn care at facilities. However, the quality of such care in India has significant gaps in terms of provider skills and in their preparedness to handle emergencies. We tested the feasibility, acceptability, and effectiveness of a "skills and drills" intervention, implemented between July 2013 and September 2014, to improve emergency obstetric and newborn care in the state of Karnataka, India. Emergency drills through role play, conducted every 2 months, combined with supportive supervision and a 2-day skills refresher session were delivered across 4 sub-district, secondary-level government facilities by an external team of obstetric and pediatric specialists and nurses. We evaluated the intervention through a quasi-experimental design with 4 intervention and 4 comparison facilities, using delivery case sheet reviews, pre- and post-knowledge tests among providers, objective structured clinical examinations (OSCEs), and qualitative in-depth interviews. Primary outcomes consisted of improved diagnosis and management of selected maternal and newborn complications (postpartum hemorrhage, pregnancy-induced hypertension, and birth asphyxia). Secondary outcomes included knowledge and skill levels of providers and acceptability and feasibility of the intervention. Knowledge scores among providers improved significantly in the intervention facilities; in obstetrics, average scores between the pre- and post-test increased from 49% to 57% (P=.006) and in newborn care, scores increased from 48% to 56% (P=.03). Knowledge scores in the comparison facilities were similar but did not improve significantly over time. Skill levels were significantly higher among providers in intervention facilities than comparison facilities (mean objective structured clinical examination scores for obstetric skills: 55% vs. 46%, respectively; for newborn skills: 58% vs. 48%, respectively; P<.001 for both obstetric and newborn), along with their confidence in managing complications. However, this did not result in significant differences in correct diagnosis and management of complications between intervention and comparison facilities. Shortage of trained nurses and doctors along with unavailability of a consistent supply chain was cited by most providers as major health systems barriers affecting provision of care. Improvements in knowledge, skills, and confidence levels of providers as a result of the skills and drills intervention was not sufficient to translate into improved diagnosis and management of maternal and newborn complications. System-level changes including adequate in-service training may also be necessary to improve maternal and newborn outcomes. © Varghese et al.

Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training

PubMed Central

Walker, Dilys M.; Cohen, Susanna R.; Fritz, Jimena; Olvera-García, Marisela; Zelek, Sarah T.; Fahey, Jenifer O.; Romero-Martínez, Martín; Montoya-Rodríguez, Alejandra; Lamadrid-Figueroa, Héctor

2016-01-01

Introduction Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. Methods We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. Results There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months’ (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. Conclusions PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes. PMID:26312613

Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training.

PubMed

Walker, Dilys M; Cohen, Susanna R; Fritz, Jimena; Olvera-García, Marisela; Zelek, Sarah T; Fahey, Jenifer O; Romero-Martínez, Martín; Montoya-Rodríguez, Alejandra; Lamadrid-Figueroa, Héctor

2016-02-01

Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months' (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes.

Bag free in the Bay State.

PubMed

Hurwitz, Anita Gupta; Farrow, Phillip R; Preer, Genevieve; Philipp, Barbara L

2014-06-01

The deleterious effect of formula company-sponsored discharge bags on breastfeeding is well established. As of July 2012, all 49 maternity facilities in Massachusetts had banned these bags, making it the second "bag-free" state in the United States. Obstacles to changing this long-standing practice were numerous, including concerns regarding the cost of a substitute gift. This study was designed to describe what practices maternity facilities in Massachusetts have adopted in place of giving out a formula company-sponsored discharge bag. Maternity facilities in Massachusetts were surveyed regarding discharge gift practices. Information was collected regarding gifts given and cost. The response rate was 100%. Fifty-nine percent of the facilities replaced the formula company-sponsored bag with their own gift bag carrying the hospital's logo. Bags were either given empty or contained educational materials and/or a gift such as a T-shirt, hat, or baby book. Fourteen percent of the facilities gave a gift that did not include a bag. Twenty-seven percent of facilities gave no gift. Cost of the gifts ranged from $1 to $35, with a mean cost of $10.67. The hospital budget was used to partially or fully fund 58% of gifts; 22% were covered in part by donations. Although most maternity facilities surveyed replaced the formula company-sponsored discharge bag with a different gift, one-quarter gave no replacement. These data indicate that discontinuing discharge gifts can be a readily accepted, cost-neutral step toward evidence-based breastfeeding best practice.

Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania.

PubMed

Nyamtema, Angelo S; Urassa, David P; Pembe, Andrea B; Kisanga, Felix; van Roosmalen, Jos

2010-06-03

Effective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved. A cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed. Overall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed. Maternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.

Can facility delivery reduce the risk of intrapartum complications-related perinatal mortality? Findings from a cohort study.

PubMed

Khanam, Rasheda; Baqui, Abdullah H; Syed, Mamun Ibne Moin; Harrison, Meagan; Begum, Nazma; Quaiyum, Abdul; Saha, Samir K; Ahmed, Saifuddin

2018-06-01

Intrapartum complications increase the risk of perinatal deaths. However, population-based data from developing countries assessing the contribution of intrapartum complications to perinatal deaths is scarce. Using data from a cohort of pregnant women followed between 2011 and 2013 in Bangladesh, this study examined the rate and types of intrapartum complications, the association of intrapartum complications with perinatal mortality, and if facility delivery modified the risk of intrapartum-related perinatal deaths. Trained community health workers (CHWs) made two-monthly home visits to identify pregnant women, visited them twice during pregnancy and 10 times in the first two months postpartum. During prenatal visits, CHWs collected data on women's prior obstetric history, socio-demographic status, and complications during pregnancy. They collected data on intrapartum complications, delivery care, and pregnancy outcome during the first postnatal visit within 7 days of delivery. We examined the association of intrapartum complications and facility delivery with perinatal mortality by estimating odds ratios (OR) and 95% confidence intervals (CI) adjusting for covariates using multivariable logistic regression analysis. The overall facility delivery rate was low (3922/24 271; 16.2%). Any intrapartum complications among pregnant women were 20.9% (5,061/24,271) and perinatal mortality was 64.7 per 1000 birth. Compared to women who delivered at home, the risk of perinatal mortality was 2.4 times higher (OR = 2.40; 95% CI = 2.08-2.76) when delivered in a public health facility and 1.3 times higher (OR = 1.32, 95% CI = 1.06-1.64) when delivered in a private health facility. Compared to women who had no intrapartum complications and delivered at home, women with intrapartum complications who delivered at home had a substantially higher risk of perinatal mortality (OR = 3.45; 95% CI = 3.04-3.91). Compared to women with intrapartum complications who delivered at home, the risk of perinatal mortality among women with intrapartum complications was 43.0% lower for women who delivered in a public health facility (OR = 0.57; 95% CI = 0.42-0.78) and 58.0% lower when delivered in a private health facility (OR = 0.42; 95% CI = 0.28-0.63). Maternal health programs need to promote timely recognition of intrapartum complications and delivery in health facilities to improve perinatal outcomes, particularly in populations where overall facility delivery rates are low. The differential risk between public and private health facilities may be due to differences in quality of care. Efforts should be made to improve the quality of care in all health facilities.

Maternal health care initiatives: Causes of morbidities and mortalities in two rural districts of Upper West Region, Ghana.

PubMed

Sumankuuro, Joshua; Crockett, Judith; Wang, Shaoyu

2017-01-01

Maternal and neonatal morbidities and mortalities have received much attention over the years in sub-Saharan Africa; yet addressing them remains a profound challenge, no more so than in the nation of Ghana. This study focuses on finding explanations to the conditions which lead to maternal and neonatal morbidities and mortalities in rural Ghana, particularly the Upper West Region. Mixed methods approach was adopted to investigate the medical and non-medical causes of maternal and neonatal morbidities and mortalities in two rural districts of the Upper West Region of Ghana. Survey questionnaires, in-depth interviews and focus group discussions were employed to collect data from: a) 80 expectant mothers (who were in their second and third trimesters, excluding those in their ninth month), b) 240 community residents and c) 13 healthcare providers (2 district directors of health services, 8 heads of health facilities and 3 nurses). Morbidity and mortality during pregnancy is attributed to direct causes such urinary tract infection (48%), hypertensive disorders (4%), mental health conditions (7%), nausea (4%) and indirect related sicknesses such as anaemia (11%), malaria, HIV/AIDS, oedema and hepatitis B (26%). Socioeconomic and cultural factors are identified as significant underlying causes of these complications and to morbidity and mortality during labour and the postnatal period. Birth asphyxia and traditional beliefs and practices were major causes of neonatal deaths. These findings provide focused targets and open a window of opportunity for the community-based health services run by Ghana Health Service to intensify health education and promotion programmes directed at reducing risky economic activities and other cultural beliefs and practices affecting maternal and neonatal morbidity and mortality.

Diagnostic methods to determine microbiology of postpartum endometritis in South Asia: laboratory methods protocol used in the Postpartum Sepsis Study: a prospective cohort study.

PubMed

Shakoor, Sadia; Reller, Megan E; LeFevre, Amnesty; Hotwani, Aneeta; Qureshi, Shahida M; Yousuf, Farheen; Islam, Mohammad Shahidul; Connor, Nicholas; Rafiqullah, Iftekhar; Mir, Fatima; Arif, Shabina; Soofi, Sajid; Bartlett, Linda A; Saha, Samir

2016-02-25

The South Asian region has the second highest risk of maternal death in the world. To prevent maternal deaths due to sepsis and to decrease the maternal mortality ratio as per the World Health Organization Millenium Development Goals, a better understanding of the etiology of endometritis and related sepsis is required. We describe microbiological laboratory methods used in the maternal Postpartum Sepsis Study, which was conducted in Bangladesh and Pakistan, two populous countries in South Asia. Postpartum maternal fever in the community was evaluated by a physician and blood and urine were collected for routine analysis and culture. If endometritis was suspected, an endometrial brush sample was collected in the hospital for aerobic and anaerobic culture and molecular detection of bacterial etiologic agents (previously identified and/or plausible). The results emanating from this study will provide microbiologic evidence of the etiology and susceptibility pattern of agents recovered from patients with postpartum fever in South Asia, data critical for the development of evidence-based algorithms for management of postpartum fever in the region.

Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study.

PubMed

Zanette, Elvira; Parpinelli, Mary Angela; Surita, Fernanda Garanhani; Costa, Maria Laura; Haddad, Samira Maerrawi; Sousa, Maria Helena; E Silva, Joao Luiz Pinto; Souza, Joao Paulo; Cecatti, Jose Guilherme

2014-01-16

Hypertensive disorders represent the major cause of maternal morbidity in middle income countries. The main objective of this study was to identify the prevalence and factors associated with severe maternal outcomes in women with severe hypertensive disorders. This was a cross-sectional, multicenter study, including 6706 women with severe hypertensive disorder from 27 maternity hospitals in Brazil. A prospective surveillance of severe maternal morbidity with data collected from medical charts and entered into OpenClinica®, an online system, over a one-year period (2009 to 2010). Women with severe preeclampsia, severe hypertension, eclampsia and HELLP syndrome were included in the study. They were grouped according to outcome in near miss, maternal death and potentially life-threatening condition. Prevalence ratios and 95% confidence intervals adjusted for cluster effect for maternal and perinatal variables and delays in receiving obstetric care were calculated as risk estimates of maternal complications having a severe maternal outcome (near miss or death). Poisson multiple regression analysis was also performed. Severe hypertensive disorders were the main cause of severe maternal morbidity (6706/9555); the prevalence of near miss was 4.2 cases per 1000 live births, there were 8.3 cases of Near Miss to 1 Maternal Death and the mortality index was 10.7% (case fatality). Early onset of the disease and postpartum hemorrhage were independent variables associated with severe maternal outcomes, in addition to acute pulmonary edema, previous heart disease and delays in receiving secondary and tertiary care. In women with severe hypertensive disorders, the current study identified situations independently associated with a severe maternal outcome, which could be modified by interventions in obstetric care and in the healthcare system. Furthermore, the study showed the feasibility of a hospital system for surveillance of severe maternal morbidity.

Widowers' accounts of maternal mortality among women of low socioeconomic status in Nigeria.

PubMed

Nwokocha, Ezebunwa Ethelbert

2012-09-01

The research is based on information collected on 50 deceased Nigerian women of low socioeconomic status in different locations of the country including Lagos, Ibadan, Kaduna, Zaria, Minna, Enugu, and Port-Harcourt among others. They had some common characteristics such as low levels of education, involvement in petty trading and were clients of a microfinance bank as small loan receivers. Primary data were generated mainly through verbal autopsy with widowers employing in-depth interviews and key informant interviews. In addition, unobtrusive observation was carried out in these locations to ascertain in some instances the distance between the deceased homes and health facilities patronised by the women. Secondary data were specific to death certificates of the deceased supplied by the widowers. Both ethnographic summaries and content analysis were employed in data analysis to account for contextual differences, especially in a multicultural society like Nigeria. The findings implicated several issues that are taken for granted at the micro-family and macro-society levels. It specifically revealed that small loans alone are not sufficient to empower poor women to make meaningful contributions to their own reproductive health in a patriarchal society like Nigeria. Results also indicated that cultural differences as well as rural-urban dichotomy were not proximate determinants of maternal behaviour; the latter rather finds expression in low socioeconomic status. Consequently, policy relevant recommendations that could contribute to significant maternal mortality reduction were proffered.

Maternal mortality in Mexico, beyond millennial development objectives: An age-period-cohort model.

PubMed

Rodríguez-Aguilar, Román

2018-01-01

The maternal mortality situation is analyzed in México as an indicator that reflects the social development level of the country and was one of the millennial development objectives. The effect of a maternal death in the related social group has multiplier effects, since it involves family dislocation, economic impact and disruption of the orphans' normal social development. Two perspectives that causes of maternal mortality were analyzed, on one hand, their relationship with social determinants and on the other, factors directly related to the health system. Evidence shows that comparing populations based on group of selected variables according to social conditions and health care access, statistically significant differences prevail according to education and marginalization levels, and access to medical care. In addition, the Age-Period-Cohort model raised, shows significant progress in terms of a downward trend in maternal mortality in a generational level. Those women born before 1980 had a greater probability of maternal death in relation to recent generations, which is a reflection of the improvement in social determinants and in the Health System. The age effect shows a problem in maternal mortality in women under 15 years old, so teen pregnancy is a priority in health and must be addressed in short term. There is no clear evidence of a period effect.

Maternal mortality in Mexico, beyond millennial development objectives: An age-period-cohort model

PubMed Central

2018-01-01

The maternal mortality situation is analyzed in México as an indicator that reflects the social development level of the country and was one of the millennial development objectives. The effect of a maternal death in the related social group has multiplier effects, since it involves family dislocation, economic impact and disruption of the orphans' normal social development. Two perspectives that causes of maternal mortality were analyzed, on one hand, their relationship with social determinants and on the other, factors directly related to the health system. Evidence shows that comparing populations based on group of selected variables according to social conditions and health care access, statistically significant differences prevail according to education and marginalization levels, and access to medical care. In addition, the Age-Period-Cohort model raised, shows significant progress in terms of a downward trend in maternal mortality in a generational level. Those women born before 1980 had a greater probability of maternal death in relation to recent generations, which is a reflection of the improvement in social determinants and in the Health System. The age effect shows a problem in maternal mortality in women under 15 years old, so teen pregnancy is a priority in health and must be addressed in short term. There is no clear evidence of a period effect. PMID:29561878

Shifting visions: "delegation" policies and the building of a "rights-based" approach to maternal mortality.

PubMed

Freedman, Lynn P

2002-01-01

"Rights-based" approaches fold human rights principles into the ongoing work of health policy making and programming. The example of delegation of anesthesia provision for emergency obstetric care is used to demonstrate how a rights-based approach, applied to this problem in the context of high-mortality countries, requires decision makers to shift from an individual, ethics-based, clinical perspective to a structural, rights-based, public health perspective. This fluid and context-sensitive approach to human rights also applies at the international level, where the direction of overall maternal mortality reduction strategy is set. By contrasting family planning programs and maternal mortality programs, this commentary argues for choosing the human rights approach that speaks most effectively to the power dynamics underlying the particular health problem being addressed. In the case of maternal death in high-mortality countries, this means a strategic focus on the health care system itself.

Women's preferences for obstetric care in rural Ethiopia: a population-based discrete choice experiment in a region with low rates of facility delivery.

PubMed

Kruk, M E; Paczkowski, M M; Tegegn, A; Tessema, F; Hadley, C; Asefa, M; Galea, S

2010-11-01

Delivery attended by skilled professionals is essential to reducing maternal mortality. Although the facility delivery rate in Ethiopia's rural areas is extremely low, little is known about which health system characteristics most influence women's preferences for delivery services. In this study, women's preferences for attributes of health facilities for delivery in rural Ethiopia were investigated. A population-based discrete choice experiment (DCE) was fielded in Gilgel Gibe, in southwest Ethiopia, among women with a delivery in the past 5 years. Women were asked to select a hypothetical health facility for future delivery from two facilities on a picture card. A hierarchical Bayesian procedure was used to estimate utilities associated with facility attributes: distance, type of provider, provider attitude, drugs and medical equipment, transport and cost. 1006 women completed 8045 DCE choice tasks. Among them, 93.8% had delivered their last child at home. The attributes with the greatest influence on the overall utility of a health facility for delivery were availability of drugs and equipment (mean β=3.9, p<0.01), seeing a doctor versus a health extension worker (mean β=2.1, p<0.01) and a receptive provider attitude (mean β=1.4, p<0.01). Women in rural southwest Ethiopia who have limited personal experience with facility delivery nonetheless value health facility attributes that indicate high technical quality: availability of drugs and equipment and physician providers. Well-designed policy experiments that measure the contribution of quality improvements to facility delivery rates in Ethiopia and other countries with low health service utilisation and high maternal mortality may inform national efforts to reduce maternal mortality.

Using Benchmarking Techniques and the 2011 Maternity Practices Infant Nutrition and Care (mPINC) Survey to Improve Performance among Peer Groups across the United States

PubMed Central

Edwards, Roger A.; Dee, Deborah; Umer, Amna; Perrine, Cria G.; Shealy, Katherine R.; Grummer-Strawn, Laurence M.

2015-01-01

Background A substantial proportion of US maternity care facilities engage in practices that are not evidence-based and that interfere with breastfeeding. The CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) showed significant variation in maternity practices among US states. Objective The purpose of this article is to use benchmarking techniques to identify states within relevant peer groups that were top performers on mPINC survey indicators related to breastfeeding support. Methods We used 11 indicators of breastfeeding-related maternity care from the 2011 mPINC survey and benchmarking techniques to organize and compare hospital-based maternity practices across the 50 states and Washington, DC. We created peer categories for benchmarking first by region (grouping states by West, Midwest, South, and Northeast) and then by size (grouping states by the number of maternity facilities and dividing each region into approximately equal halves based on the number of facilities). Results Thirty-four states had scores high enough to serve as benchmarks, and 32 states had scores low enough to reflect the lowest score gap from the benchmark on at least 1 indicator. No state served as the benchmark on more than 5 indicators and no state was furthest from the benchmark on more than 7 indicators. The small peer group benchmarks in the South, West, and Midwest were better than the large peer group benchmarks on 91%, 82%, and 36% of the indicators, respectively. In the West large, the Midwest large, the Midwest small, and the South large peer groups, 4–6 benchmarks showed that less than 50% of hospitals have ideal practice in all states. Conclusion The evaluation presents benchmarks for peer group state comparisons that provide potential and feasible targets for improvement. PMID:24394963

Community health promotion and medical provision for neonatal health-CHAMPION cluster randomised trial in Nagarkurnool district, Telangana (formerly Andhra Pradesh), India.

PubMed

Boone, Peter; Eble, Alex; Elbourne, Diana; Frost, Chris; Jayanty, Chitra; Lakshminarayana, Rashmi; Mann, Vera; Mukherjee, Rohini; Piaggio, Gilda; Reddy, Padmanabh

2017-07-01

In the mid-2000s, neonatal mortality accounted for almost 40% of deaths of children under 5 years worldwide, and constituted 65% of infant deaths in India. The neonatal mortality rate in Andhra Pradesh was 44 per 1,000 live births, and was higher in the rural areas and tribal regions, such as the Nagarkurnool division of Mahabubnagar district (which became Nagarkurnool district in Telangana in 2014). The aim of the CHAMPION trial was to investigate whether a package of interventions comprising community health promotion and provision of health services (including outreach and facility-based care) could lead to a reduction of the order of 25% in neonatal mortality. The design was a trial in which villages (clusters) in Nagarkurnool with a population < 2,500 were randomised to the CHAMPION package of health interventions or to the control arm (in which children aged 6-9 years were provided with educational interventions-the STRIPES trial). A woman was eligible for the CHAMPION package if she was married and <50 years old, neither she nor her husband had had a family planning operation, and she resided in a trial village at the time of a baseline survey before randomisation or married into the village after randomisation. The CHAMPION intervention package comprised community health promotion (including health education via village health worker-led participatory discussion groups) and provision of health services (including outreach, with mobile teams providing antenatal check-ups, and facility-based care, with subsidised access to non-public health centres [NPHCs]). Villages were stratified by travel time to the nearest NPHC and tribal status, and randomised (1:1) within strata. The primary outcome was neonatal mortality. Secondary outcomes included maternal mortality, causes of death, health knowledge, health practices including health service usage, satisfaction with care, and costs. The baseline survey (enumeration) was carried out between August and November 2007. After randomisation on 18 February 2008, participants, data collectors, and data analysts were not masked to allocation. The intervention was initiated on 1 August 2008. After an inception period, the assessment start date was 1 December 2008. The intervention ended on 31 May 2011, and data collection was completed on 30 November 2011. Primary analyses followed the intention to treat principle. In all, 14,137 women were enrolled in 232 control villages, and 15,532 in 232 intervention villages. Of these, 4,885 control women had 5,474 eligible pregnancies and gave birth to 4,998 eligible children. The corresponding numbers in intervention villages were 5,664 women, 6,351 pregnancies, and 5,798 children. Of the live-born babies, 343 (6.9%) in the control arm and 303 (5.2%) in the intervention arm died in their first 28 days of life (risk ratio 0.76, 95% CI 0.64 to 0.90, p = 0.0018; risk difference -1.59%, 95% CI -2.63% to -0.54%), suggesting that there were 92 fewer deaths (95% CI 31 to 152) as a result of the intervention. There were 9 (0.16%) maternal deaths in the control arm compared to 13 (0.20%) in the intervention arm (risk ratio 1.24, 95% CI 0.53 to 2.90, p = 0.6176; 1 death was reported as a serious adverse event). There was evidence of improved health knowledge and health practices including health service usage in the intervention arm compared to the control arm. Women in the intervention arm were more likely to rate their delivery and postnatal care as good or very good. The total cost of the CHAMPION interventions was US$1,084,955 ($11,769 per life saved, 95% CI $7,115 to $34,653). The main limitations of the study included that it could not be masked post-randomisation and that fetal losses were not divided into stillbirths and miscarriages because gestational age was not reliably reported. The CHAMPION trial showed that a package of interventions addressing health knowledge and health seeking behaviour, buttressing existing health services, and contracting out important areas of maternal and child healthcare led to a reduction in neonatal mortality of almost the hypothesized 25% in small villages in an Indian state with high mortality rates. The intervention can be strongly justified in much of rural India, and is of potential use in other similar settings. Ongoing changes in maternal and child health programmes make it imperative that a similar intervention that establishes ties between the community and health facilities is tested in different settings. ISRCTN registry ISRCTN24104646.

Community health promotion and medical provision for neonatal health—CHAMPION cluster randomised trial in Nagarkurnool district, Telangana (formerly Andhra Pradesh), India

PubMed Central

Boone, Peter; Eble, Alex; Frost, Chris; Mann, Vera; Reddy, Padmanabh

2017-01-01

Background In the mid-2000s, neonatal mortality accounted for almost 40% of deaths of children under 5 years worldwide, and constituted 65% of infant deaths in India. The neonatal mortality rate in Andhra Pradesh was 44 per 1,000 live births, and was higher in the rural areas and tribal regions, such as the Nagarkurnool division of Mahabubnagar district (which became Nagarkurnool district in Telangana in 2014). The aim of the CHAMPION trial was to investigate whether a package of interventions comprising community health promotion and provision of health services (including outreach and facility-based care) could lead to a reduction of the order of 25% in neonatal mortality. Methods and findings The design was a trial in which villages (clusters) in Nagarkurnool with a population < 2,500 were randomised to the CHAMPION package of health interventions or to the control arm (in which children aged 6–9 years were provided with educational interventions—the STRIPES trial). A woman was eligible for the CHAMPION package if she was married and <50 years old, neither she nor her husband had had a family planning operation, and she resided in a trial village at the time of a baseline survey before randomisation or married into the village after randomisation. The CHAMPION intervention package comprised community health promotion (including health education via village health worker–led participatory discussion groups) and provision of health services (including outreach, with mobile teams providing antenatal check-ups, and facility-based care, with subsidised access to non-public health centres [NPHCs]). Villages were stratified by travel time to the nearest NPHC and tribal status, and randomised (1:1) within strata. The primary outcome was neonatal mortality. Secondary outcomes included maternal mortality, causes of death, health knowledge, health practices including health service usage, satisfaction with care, and costs. The baseline survey (enumeration) was carried out between August and November 2007. After randomisation on 18 February 2008, participants, data collectors, and data analysts were not masked to allocation. The intervention was initiated on 1 August 2008. After an inception period, the assessment start date was 1 December 2008. The intervention ended on 31 May 2011, and data collection was completed on 30 November 2011. Primary analyses followed the intention to treat principle. In all, 14,137 women were enrolled in 232 control villages, and 15,532 in 232 intervention villages. Of these, 4,885 control women had 5,474 eligible pregnancies and gave birth to 4,998 eligible children. The corresponding numbers in intervention villages were 5,664 women, 6,351 pregnancies, and 5,798 children. Of the live-born babies, 343 (6.9%) in the control arm and 303 (5.2%) in the intervention arm died in their first 28 days of life (risk ratio 0.76, 95% CI 0.64 to 0.90, p = 0.0018; risk difference −1.59%, 95% CI −2.63% to −0.54%), suggesting that there were 92 fewer deaths (95% CI 31 to 152) as a result of the intervention. There were 9 (0.16%) maternal deaths in the control arm compared to 13 (0.20%) in the intervention arm (risk ratio 1.24, 95% CI 0.53 to 2.90, p = 0.6176; 1 death was reported as a serious adverse event). There was evidence of improved health knowledge and health practices including health service usage in the intervention arm compared to the control arm. Women in the intervention arm were more likely to rate their delivery and postnatal care as good or very good. The total cost of the CHAMPION interventions was US$1,084,955 ($11,769 per life saved, 95% CI $7,115 to $34,653). The main limitations of the study included that it could not be masked post-randomisation and that fetal losses were not divided into stillbirths and miscarriages because gestational age was not reliably reported. Conclusions The CHAMPION trial showed that a package of interventions addressing health knowledge and health seeking behaviour, buttressing existing health services, and contracting out important areas of maternal and child healthcare led to a reduction in neonatal mortality of almost the hypothesized 25% in small villages in an Indian state with high mortality rates. The intervention can be strongly justified in much of rural India, and is of potential use in other similar settings. Ongoing changes in maternal and child health programmes make it imperative that a similar intervention that establishes ties between the community and health facilities is tested in different settings. Trial registration ISRCTN registry ISRCTN24104646 PMID:28678849

Causes of maternal mortality decline in Matlab, Bangladesh.

PubMed

Chowdhury, Mahbub Elahi; Ahmed, Anisuddin; Kalim, Nahid; Koblinsky, Marge

2009-04-01

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality--86.7% and 78.3%--in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential.

Causes of Maternal Mortality Decline in Matlab, Bangladesh

PubMed Central

Ahmed, Anisuddin; Kalim, Nahid; Koblinsky, Marge

2009-01-01

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality—86.7% and 78.3%—in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential. PMID:19489410

Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya

PubMed Central

Bellows, Ben; Kyobutungi, Catherine; Mutua, Martin Kavao; Warren, Charlotte; Ezeh, Alex

2013-01-01

Objective To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements. Data sources Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004–05 and 2006–08. Methods Odds of facility-based delivery were estimated before and after introduction of an output-based voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003–10) and vaccination coverage (2003–09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006–10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother’s place of delivery, NUHDSS-MCH recorded the use of the voucher. Findings There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12–23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the voucher programme. Conclusions A positive association was observed between vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations. PMID:22437506

Obstetric Facility Quality and Newborn Mortality in Malawi: A Cross-Sectional Study

PubMed Central

Fink, Günther; Nsona, Humphreys

2016-01-01

Background Ending preventable newborn deaths is a global health priority, but efforts to improve coverage of maternal and newborn care have not yielded expected gains in infant survival in many settings. One possible explanation is poor quality of clinical care. We assess facility quality and estimate the association of facility quality with neonatal mortality in Malawi. Methods and Findings Data on facility infrastructure as well as processes of routine and basic emergency obstetric care for all facilities in the country were obtained from 2013 Malawi Service Provision Assessment. Birth location and mortality for children born in the preceding two years were obtained from the 2013–2014 Millennium Development Goals Endline Survey. Facilities were classified as higher quality if they ranked in the top 25% of delivery facilities based on an index of 25 predefined quality indicators. To address risk selection (sicker mothers choosing or being referred to higher-quality facilities), we employed instrumental variable (IV) analysis to estimate the association of facility quality of care with neonatal mortality. We used the difference between distance to the nearest facility and distance to a higher-quality delivery facility as the instrument. Four hundred sixty-seven of the 540 delivery facilities in Malawi, including 134 rated as higher quality, were linked to births in the population survey. The difference between higher- and lower-quality facilities was most pronounced in indicators of basic emergency obstetric care procedures. Higher-quality facilities were located a median distance of 3.3 km further from women than the nearest delivery facility and were more likely to be in urban areas. Among the 6,686 neonates analyzed, the overall neonatal mortality rate was 17 per 1,000 live births. Delivery in a higher-quality facility (top 25%) was associated with a 2.3 percentage point lower newborn mortality (95% confidence interval [CI] -0.046, 0.000, p-value 0.047). These results imply a newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities, accounting for maternal and newborn characteristics. This estimate applies to newborns whose mothers would switch from a lower-quality to a higher-quality facility if one were more accessible. Although we did not find an indication of unmeasured associations between the instrument and outcome, this remains a potential limitation of IV analysis. Conclusions Poor quality of delivery facilities is associated with higher risk of newborn mortality in Malawi. A shift in focus from increasing utilization of delivery facilities to improving their quality is needed if global targets for further reductions in newborn mortality are to be achieved. PMID:27755547

Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts.

PubMed

Singh, Prashant Kumar; Kumar, Chandan; Rai, Rajesh Kumar; Singh, Lucky

2014-08-01

Studies have often ignored examining the role of community- and district-level factors in the utilization of maternity healthcare services, particularly in Indian contexts. The Social Determinants of Health framework emphasizes the role of governance and government policies, the measures for which are rarely incorporated in single-level individual analysis. This study examines factors associated with maternal healthcare utilization in nine high focus states in India, which shares more than half of the total maternal deaths in the country; accounting for individual-, household-, community- and district-level characteristics. The required data are extracted from the third round of the nationally representative District Level Household and Facility Survey conducted during 2007-08. Multilevel analyses were applied to three maternity outcomes, namely, four or more antenatal care visits, skilled birth attendance and post-natal care after birth. Results show that along with individual-/household-level factors, community and district-level factors influence the pattern of utilization of maternal healthcare services significantly. At the community level, the odds of maternal healthcare utilization were lower in rural areas and in communities with a high concentration of poor and illiterate women. Moreover, the average population coverage of primary health centres (PHCs), availability of labour room in PHC and percentage of registered pregnancies were significant factors at the district level that influenced the use of maternity care services. The study also found a strong association between the extent of previous use of maternal healthcare and its effect on subsequent usage patterns. This study highlights the role of strengthening public health infrastructure at district level in the study area, and promoting awareness about available healthcare services and subsidized schemes in the community. To reach out to rural and underprivileged communities and to apply a participatory approach from the programme officials are issues to delve into. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.

Alcohol consumption in relation to maternal deaths from induced-abortions in Ghana

PubMed Central

2012-01-01

Introduction The fight against maternal deaths has gained attention as the target date for Millennium Development Goal 5 approaches. Induced-abortion is one of the leading causes of maternal deaths in developing countries which hamper this effort. In Ghana, alcohol consumption and unwanted pregnancies are on the ascendancy. We examined the association between alcohol consumption and maternal mortality from induced-abortion. We further analyzed the factors that lie behind the alcohol consumption patterns in the study population. Method The data we used was extracted from the Ghana Maternal Health Survey 2007. This was a national survey conducted across the 10 administrative regions of Ghana. The survey identified 4203 female deaths through verbal autopsy, among which 605 were maternal deaths in the 12 to 49 year-old age group. Analysis was done using Statistical software IBM SPSS Statistics 20. A case control study design was used. Cross-tabulations and logistic regression models were used to investigate associations between the different variables. Results Alcohol consumption was significantly associated with abortion-related maternal deaths. Women who had ever consumed alcohol (OR adjusted 2.6, 95% CI 1.38–4.87), frequent consumers (OR adjusted 2.6, 95% CI 0.89–7.40) and occasional consumers (OR adjusted 2.7, 95% CI 1.29–5.46) were about three times as likely to die from abortion-related causes compared to those who abstained from alcohol. Maternal age, marital status and educational level were found to have a confounding effect on the observed association. Conclusion Policy actions directed toward reducing abortion-related deaths should consider alcohol consumption, especially among younger women. Policy makers in Ghana should consider increasing the legal age for alcohol consumption. We suggest that information on the health risks posed by alcohol and abortion be disseminated to communities in the informal sector where vulnerable groups can best be reached. PMID:22867435

Trends in concurrent maternal and perinatal deaths at a teaching hospital in Ghana: the facts and prevention strategies.

PubMed

Lassey, Anyetei T; Obed, Sam A

2004-09-01

To determine the trend of concurrent maternal and perinatal mortality at the Korle-Bu Teaching Hospital (KBTH), Ghana, and to propose measures for its prevention. A retrospective study, from January 1995 to December 2002, of all concurrent maternal and perinatal deaths in which the woman was 28 weeks' gestation or more (or, if gestational age was not known, the baby weighed 1000 g or more) and died either undelivered or in the perinatal period (within 1 week of delivery) at the KBTH. Over the 8-year study period, there was a total of 93 622 deliveries at the KBTH with 108 concurrent maternal and perinatal mortalities, giving a ratio of 115.4 concurrent maternal and perinatal deaths per 100 000 deliveries. More than 80% of the mothers who died had little or no formal education. Of the 108 mothers, 22 died undelivered. The leading cause of death was a medical condition in pregnancy along with eclampsia/gestational hypertension. Of the 86 delivered mothers, the leading cause of concurrent death was a medical condition in pregnancy. Approximately two-thirds (72/108) of the perinatal deaths were stillbirths. Over the study period, there was a rising trend of the obstetric disaster of losing both mother and baby. There is a rising trend of concurrent maternal and perinatal mortality at the KBTH. It is suggested that a regular antenatal clinic be established with both an internist and obstetrician to jointly see and manage women with medical problems. There is a need for improved and adequate resources to improve outcomes for both mother and baby. A waiver of user fees for maternity services may be one way to improve access for needy and at-risk mothers. Concurrent maternal and perinatal death is the latest negative reproductive health index of the deteriorating socioeconomic situation in developing countries and needs to be tackled decisively.

Induced abortion in sub-Saharan Africa.

PubMed

Rogo, K O

1993-06-01

Unsafe abortions and their complications are a major cause of maternal mortality. Hospital based studies from most African countries confirm that up to 50% of maternal deaths are due to abortion. This paper reviews problem of induced abortion in sub-Saharan Africa. Issues of prevalence and prevention are addressed while acknowledging the need to review the legal regimes operating in these countries.

Birth preparedness and complication readiness in Robe Woreda, Arsi Zone, Oromia Region, Central Ethiopia: a cross-sectional study

PubMed Central

2014-01-01

Background Globally, an estimated 287 000 maternal deaths occurred in 2010 annually as a result of complications of pregnancy and childbirth. Sub-Saharan Africa and Southern Asia were accounted for 85% of the global burden (245 000 maternal deaths) including Ethiopia. Obstetric related complications cannot be reliably predicted. Hence, insignificant decline of maternal mortality ratio might be due to the non use of birth preparedness and complication readiness strategies. Therefore, this paper aimed to assess knowledge and practices towards birth preparedness and complication readiness and associated factors among women of reproductive age group (15–49) in Robe Woreda, Arsi Zone, Oromia Region, Ethiopia. Method Community-based cross-sectional study supplemented by qualitative design was conducted in January, 2012. A total of 575 women from 5 kebeles were selected after proportionally allocated to population size and interviewed using structured and semi-structured, pre-tested questionnaires. Univariate and bivariate analysis was performed. Multiple logistic regression analysis was also done to control for possible confounding variables. Results Taking into account place of delivery identification, means of transportation, skilled attendant identification and saving money, about 16.5% of the respondents were prepared for birth and its complications. Preparation for birth and its complication was higher among educated mothers (AOR = 6.23, 95% CI = 1.5, 25.87). Monthly income of >716 Ethiopian birr (AOR = 1.94, 95% CI = 1.01, 3.87), ANC visit (AOR = 5.68, 95% CI = 1.27, 25.4), knowledge of obstetric complications (AOR = 2.94, 95% CI = 1.61, 5.37) and those who had given birth at health facility before their last delivery (AOR = 3.9, 95% CI = 2.04, 7.46) were also significantly associated with birth preparedness and complication readiness. Conclusion The study identified very low magnitude of birth preparedness and complication readiness in the study area and poor knowledge and practices of preparation for birth and its complication. Community education about preparation for birth and its complication and empowerment of women through expansion of educational opportunities are important steps in improving birth preparedness. In all health facilities during antenatal care emphasis should given to preparation for birth and its complication and provide information and education to all pregnant women. PMID:25038820

[Perinatal mortality due to congenital syphilis: a quality-of-care indicator for women's and children's healthcare].

PubMed

Saraceni, Valéria; Guimarães, Maria Helena Freitas da Silva; Theme Filha, Mariza Miranda; Leal, Maria do Carmo

2005-01-01

Syphilis is a persistent cause of perinatal mortality in Rio de Janeiro, Brazil, where this study was performed using data from the mortality data system and investigational reports for fetal and neonatal deaths, mandatory in municipal maternity hospitals. From 1996 to 1998, 13.1% of fetal deaths and 6.5% of neonatal deaths in municipal maternity hospitals were due to congenital syphilis. From 1999 to 2002, the proportions were 16.2% and 7.9%, respectively. For the city of Rio de Janeiro as a whole from 1999 and 2002, the proportions were 5.4% of fetal deaths and 2.2% of neonatal deaths. The perinatal mortality rate due to congenital syphilis remains stable in Rio de Janeiro, despite efforts initiated with congenital syphilis elimination campaigns in 1999 and 2000. We propose that the perinatal mortality rate due to congenital syphilis be used as an impact indicator for activities to control and eliminate congenital syphilis, based on the investigational reports for fetal and neonatal deaths. Such reports could be extended to the surveillance of other avoidable perinatal disease outcomes.

Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007

PubMed Central

Koch, Elard; Thorp, John; Bravo, Miguel; Gatica, Sebastián; Romero, Camila X.; Aguilera, Hernán; Ahlers, Ivonne

2012-01-01

Background The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs). Methods Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957–2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques. Results During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (−13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (−1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (−69.2%). The slope of the MMR did not appear to be altered by the change in abortion law. Conclusion Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion. PMID:22574194

Predictors of person-centered maternity care: the role of socioeconomic status, empowerment, and facility type.

PubMed

Afulani, Patience A; Sayi, Takudzwa S; Montagu, Dominic

2018-05-11

Low use of maternal health services, as well as poor quality care, contribute to the high maternal mortality in sub-Saharan Africa (SSA). In particular, poor person-centered maternity care (PCMC), which captures user experience, contributes both directly to pregnancy outcomes and indirectly through decreased demand for services. While many studies have examined disparities in use of maternal health services, few have examined disparities in quality of care, and none to our knowledge has empirically examined disparities in PCMC in SSA. The aim of this study is to examine factors associated with PCMC, particularly the role of household wealth, personal empowerment, and type of facility. Data are from a survey conducted in western Kenya in 2016, with women aged 15 to 49 years who delivered in the 9 weeks preceding the survey (N = 877). PCMC is operationalized as a summative score based on responses to 30 items in the PCMC scale capturing dignity and respect, communication and autonomy, and supportive care. We find that net of other factors; wealthier, employed, literate, and married women report higher PCMC than poorer, unemployed, illiterate, and unmarried women respectively. Also, women who have experienced domestic violence report lower PCMC than those who have never experienced domestic violence. In addition, women who delivered in health centers and private facilities reported higher PCMC than those who delivered in public hospitals. The effect of employment and facility type is conditional on wealth, and is strongest for the poorest women. Poor women who are unemployed and poor women who deliver in higher-level facilities receive the lowest quality PCMC. The findings imply the most disadvantaged women receive the lowest quality PCMC, especially when they seek care in higher-level facilities. Interventions to reduce disparities in PCMC are essential to improve maternal outcomes among disadvantaged groups.

Community-based scheduled screening and treatment of malaria in pregnancy for improved maternal and infant health in The Gambia, Burkina Faso and Benin: study protocol for a randomized controlled trial.

PubMed

Scott, Susana; Mens, Petra F; Tinto, Halidou; Nahum, Alain; Ruizendaal, Esmée; Pagnoni, Franco; Grietens, Koen Peeters; Kendall, Lindsay; Bojang, Kalifa; Schallig, Henk; D'Alessandro, Umberto

2014-08-28

In sub-Saharan Africa, malaria continues to cause over 10,000 maternal deaths and 75,000 to 200,000 infant deaths. Successful control of malaria in pregnancy could save lives of mothers and babies and is an essential part of antenatal care in endemic areas. The primary objective is to determine the protective efficacy of community-scheduled screening and treatment (CSST) using community health workers (CHW) against the primary outcome of prevalence of placental malaria. The secondary objectives are to determine the protective efficacy of CSST on maternal anaemia, maternal peripheral infection, low birth weight, selection of sulfadoxine-pyrimethamine (SP) resistance markers, and on antenatal clinic (ANC) attendance and coverage of intermittent preventive treatment during pregnancy (IPTp-SP). This is a multi-centre cluster-randomised controlled trial involving three countries with varying malaria endemicity; low (The Gambia) versus high transmission (Burkina Faso and Benin), and varying degrees of SP resistance (high in Benin and moderate in Gambia and Burkina Faso). CHW and their related catchment population who are randomised into the intervention arm will receive specific training on community-based case management of malaria in pregnancy. All women in both study arms will be enrolled at their first ANC visits in their second trimester where they will receive their first dose of IPTp-SP. Thereafter, CHW in the intervention arm will perform scheduled monthly screening and treatment in the womens homes. At time of delivery, a placental biopsy will be collected from all women to determine placental malaria. At each contact point, filter paper and blood slides will be collected for detection of malaria infection and SP resistance markers. To reach successful global malaria control, there is an urgent need to access those at greatest risk of malaria infection. The project is designed to develop a low-cost intervention in pregnant women which will have an immediate impact on the malaria burden in resource-limited countries. This will be done by adding to the standard IPTp-SP delivered through the health facilities: an "extension" strategy to the communities in rural areas thus bringing health services closer to where women live. Current Controlled Trials: ISRCTN37259296 (5 July 2013), and clinicaltrials.gov: NCT01941264 (10 September 2013).

Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance.

PubMed

Biswas, Animesh; Rahman, Fazlur; Eriksson, Charli; Halim, Abdul; Dalal, Koustuv

2016-08-23

Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh. Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses. Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths. SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Travel time to maternity care and its effect on utilization in rural Ghana: a multilevel analysis.

PubMed

Masters, Samuel H; Burstein, Roy; Amofah, George; Abaogye, Patrick; Kumar, Santosh; Hanlon, Michael

2013-09-01

Rates of neonatal and maternal mortality are high in Ghana. In-facility delivery and other maternal services could reduce this burden, yet utilization rates of key maternal services are relatively low, especially in rural areas. We tested a theoretical implication that travel time negatively affects the use of in-facility delivery and other maternal services. Empirically, we used geospatial techniques to estimate travel times between populations and health facilities. To account for uncertainty in Ghana Demographic and Health Survey cluster locations, we adopted a novel approach of treating the location selection as an imputation problem. We estimated a multilevel random-intercept logistic regression model. For rural households, we found that travel time had a significant effect on the likelihood of in-facility delivery and antenatal care visits, holding constant education, wealth, maternal age, facility capacity, female autonomy, and the season of birth. In contrast, a facility's capacity to provide sophisticated maternity care had no detectable effect on utilization. As the Ghanaian health network expands, our results suggest that increasing the availability of basic obstetric services and improving transport infrastructure may be important interventions. Copyright © 2013 Elsevier Ltd. All rights reserved.

Life saving or money wasting? Perceptions of caesarean sections among users of services in rural Bangladesh.

PubMed

Parkhurst, Justin Oliver; Rahman, Syed Azizur

2007-03-01

Bangladesh has a high level of maternal mortality, corresponding to one of the world's lowest rates of use of skilled birth attendance (12.1%), and a similarly low rate of caesarean births (2.4%). While increasing the proportion of women who deliver with professional medical care is essential to prevent maternal deaths, past work has identified distrust of caesarean procedures in Bangladesh. The reasons behind this distrust can manifest itself in health seeking behaviour around maternal care. This paper presents findings from a qualitative study of 30 women in a rural district of Bangladesh who recently delivered in a health facility. It finds that the distrust in doctor's recommendations for surgery stemmed from high costs incurred and a belief that it was used when not medically justified. This could lead to women avoiding or leaving medical facilities in extreme cases. Some women's experiences further illustrated disagreement among medical staff as to whether or not a caesarean procedure should be done, with conflicting financial incentives for doctors to perform caesarean deliveries, and for nurses and midwives to conduct normal deliveries. Policy makers must recognise that the fears women hold of caesarean deliveries may not simply be rooted in ignorance and may, in fact, reflect legitimate concerns with medical practice. Ultimately, it will be essential to address problems in the health systems environment, which may promote improper service provision.

Overview, methods and results of multi-country community-based maternal and newborn care economic analysis.

PubMed

Daviaud, Emmanuelle; Owen, Helen; Pitt, Catherine; Kerber, Kate; Bianchi Jassir, Fiorella; Barger, Diana; Manzi, Fatuma; Ekipara-Kiracho, Elizabeth; Greco, Giulia; Waiswa, Peter; Lawn, Joy E

2017-10-01

Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted < GDP/capita) by WHO threshold even if they only achieved a reduction of 1 neonatal death per 1000 live births. These results contribute useful information for implementation planning and sustainability of CBMNC programmes. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Why do women prefer home births in Ethiopia?

PubMed

Shiferaw, Solomon; Spigt, Mark; Godefrooij, Merijn; Melkamu, Yilma; Tekie, Michael

2013-01-16

Skilled attendants during labor, delivery, and in the early postpartum period, can prevent up to 75% or more of maternal death. However, in many developing countries, very few mothers make at least one antenatal visit and even less receive delivery care from skilled professionals. The present study reports findings from a region where key challenges related to transportation and availability of obstetric services were addressed by an ongoing project, giving a unique opportunity to understand why women might continue to prefer home delivery even when facility based delivery is available at minimal cost. The study took place in Ethiopia using a mixed study design employing a cross sectional household survey among 15-49 year old women combined with in-depth interviews and focus group discussions. Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) for their most recent birth in the one year preceding the survey. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. The most important reasons for not seeking institutional delivery were the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). The group discussions and interviews identified several reasons for the preference of traditional birth attendants over health facilities. Traditional birth attendants were seen as culturally acceptable and competent health workers. Women reported poor quality of care and previous negative experiences with health facilities. In addition, women's low awareness on the advantages of skilled attendance at delivery, little role in making decisions (even when they want), and economic constraints during referral contribute to the low level of service utilization. The study indicated the crucial role of proper health care provider-client communication and providing a more client centered and culturally sensitive care if utilization of existing health facilities is to be maximized. Implications of findings for maternal health programs and further research are discussed.

Temporal evolution and spatial distribution of maternal death

PubMed Central

Carreno, Ioná; Bonilha, Ana Lúcia de Lourenzi; da Costa, Juvenal Soares Dias

2014-01-01

OBJECTIVE To analyze the temporal evolution of maternal mortality and its spatial distribution. METHODS Ecological study with a sample made up of 845 maternal deaths in women between 10 and 49 years, registered from 1999 to 2008 in the state of Rio Grande do Sul, Southern Brazil. Data were obtained from Information System on Mortality of Ministry of Health. The maternal mortality ratio and the specific maternal mortality ratio were calculated from records, and analyzed by the Poisson regression model. In the spatial distribution, three maps of the state were built with the rates in the geographical macro-regions, in 1999, 2003, and 2008. RESULTS There was an increase of 2.0% in the period of ten years (95%CI 1.00;1.04; p = 0.01), with no significant change in the magnitude of the maternal mortality ratio. The Serra macro-region presented the highest maternal mortality ratio (1.15, 95%CI 1.08;1.21; p < 0.001). Most deaths in Rio Grande do Sul were of white women over 40 years, with a lower level of education. The time of delivery/abortion and postpartum are times of increased maternal risk, with a greater negative impact of direct causes such as hypertension and bleeding. CONCLUSIONS The lack of improvement in maternal mortality ratio indicates that public policies had no impact on women’s reproductive and maternal health. It is needed to qualify the attention to women’s health, especially in the prenatal period, seeking to identify and prevent risk factors, as a strategy of reducing maternal death. PMID:25210825

Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care.

PubMed

Cecatti, J G; Costa, M L; Haddad, S M; Parpinelli, M A; Souza, J P; Sousa, M H; Surita, F G; Pinto E Silva, J L; Pacagnella, R C; Passini, R

2016-05-01

To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome. Multicentre cross-sectional study. Twenty-seven referral maternity hospitals from all regions of Brazil. Cases of SMM identified among 82 388 delivering women over a 1-year period. Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death. Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care. Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths. This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions. Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil. © 2015 Royal College of Obstetricians and Gynaecologists.

Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo

PubMed Central

McCarthy, Katharine J.; Braganza, Sandra; Fiori, Kevin; Gbeleou, Christophe; Kpakpo, Vivien; Lopez, Andrew; Schechter, Jennifer; Singham Goodwin, Alicia; Jones, Heidi E.

2017-01-01

Objective In Togo, substantial progress in maternal and child health is needed to reach global development goals. To better inform clinic and community-based health services, this study identifies factors associated with maternal and child health care utilization in the Kara region of Northern Togo. Methods We conducted a population-representative household survey of four health clinic catchment areas of 1,075 women of reproductive age in 2015. Multivariable logistic regression was used to model individual and structural factors associated with utilization of four maternal and child health services. Key outcomes were: facility-based delivery, maternal postnatal health check by a health professional within the first six weeks of birth, childhood vaccination, and receipt of malaria medication for febrile children under age five within 72 hours of symptom onset. Results 83 percent of women who gave birth in the last 2 years delivered at a health facility. In adjusted models, the strongest predictor of facility delivery in the rural catchment areas was proximity to a health center, with women living under three kilometers having 3.7 (95% CI 1.7, 7.9) times the odds of a facility birth. Only 11 percent of women received a health check by a health provider at any time in the postnatal period. Postnatal health checks were less likely for women in the poorest households and for women who resided in rural areas. Children of polygamous mothers had half the odds of receiving malaria medication for fever within 72 hours of symptom onset, while children with increased household wealth status had increased odds of childhood vaccination and receiving treatment for malaria. Conclusion Our analysis highlights the importance of risk stratification analysis to inform the delivery and scope of maternal and child health programs needed to reach those with the least access to care. PMID:28301539

Developing a community driven sustainable model of maternity waiting homes for rural Zambia.

PubMed

Lori, Jody R; Munro-Kramer, Michelle L; Mdluli, Eden Ahmed; Musonda Mrs, Gertrude K; Boyd, Carol J

2016-10-01

maternity waiting homes (MWHs) are residential dwellings located near health facilities where women in the late stages of pregnancy stay to await childbirth and receive immediate postpartum services. These shelters help overcome distance and transportation barriers that prevent women from receiving timely skilled obstetric care. the purpose of this study was to explore Zambian stakeholders' beliefs regarding the acceptability, feasibility, and sustainability of maternity waiting homes (MWHs) to inform a model for rural Zambia. a qualitative design using a semi-structured interview guide for data collection was used. two rural districts in the Eastern province of Zambia. individual interviews were conducted with community leaders (n=46). Focus groups were held with Safe Motherhood Action Groups, husbands, and women of childbearing age in two rural districts in Zambia (n=500). latent content analysis was used to analyze the data. participants were overwhelmingly in support of MWHs as a way to improve access to facility-based childbirth and address the barrier of distance. Data suggest that participants can describe features of high quality care, and the type of care they expect from a MWH. Stakeholders acknowledged the need to contribute to the maintenance of the MWH, and that community involvement was crucial to MWH sustainability. access to facility childbirth remains particularly challenging in rural Zambia and delays in seeking care exist. Maternity waiting homes offer a feasible and acceptable intervention to reduce delays in seeking care, thereby holding the potential to improve maternal outcomes. this study joins a growing literature on the acceptability, feasibility, and sustainability of MWHs. It is believed that MWHs, by addressing the distance and transportation barriers, will increase the use of skilled birth attendants, thereby reducing maternal and neonatal morbidity and mortality in rural, low resource areas of Zambia. We recommend that any initiative, such as MWHs, seeking to increase facility-based births with a skilled birth attendant also concurrently addresses any local deficiencies in quality of care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Financial incentives to influence maternal mortality in a low-income setting: making available 'money to transport' - experiences from Amarpatan, India.

PubMed

De Costa, Ayesha; Patil, Rajkumar; Kushwah, Surgiv Singh; Diwan, Vinod Kumar

2009-03-18

Only 40.7% women in India deliver in an institution; leaving many vulnerable to maternal morbidity and mortality (India has 22% of global maternal deaths). While limited accessibility to functioning institutions may account in part, a common reason why women deliver at home is poverty. A lack of readily available financial resources for families to draw upon at the time of labor to transport the mother to an institution, is often observed. This paper reports a yearlong collaborative intervention (between the University and Department of Health) to study if providing readily available and easily accessible funds for emergency transportation would reduce maternal deaths in a rural, low income, and high maternal mortality setting in central India. It aimed to obviate a deterrent to emergency obstetric care; the non-availability of resources with mothers when most needed. Issues in implementation are also discussed. Maternal deaths were actively identified in block Amarpatan (0.2 million population) over a 2-year period. The project, with participation from local government and other groups, trained 482 local health care providers (public and private) to provide antenatal care. Emergency transport money (in cash) was placed with one provider in each village. Maternal mortality in the adjacent block (Maihar) was followed (as a 'control' block). Maternal deaths in Amarpatan decreased during the project year relative to the previous year, or in the control block the same year. Issues in implementation of the cash incentive scheme are discussed. Although the intervention reduced maternal deaths in this low-income setting, chronic poverty and malnutrition are underlying structural problems that need to be addressed.

Maternal death in the emergency department from trauma.

PubMed

Brookfield, Kathleen F; Gonzalez-Quintero, Victor H; Davis, James S; Schulman, Carl I

2013-09-01

Trauma during pregnancy is among leading causes of non-pregnancy-related maternal death (MD). This study describes risk factors for MD from trauma during pregnancy in a large urban population. We queried an urban Level One Trauma Center registry for the medical records of pregnant women suffering trauma from 1990 to 2007. Associations were examined between maternal demographics, injury mode details, injury characteristics, and risk of maternal death upon arrival to the emergency room. Overall, 351 patients were identified. Most traumas was caused by motor vehicle collision (71.8 %), accounting for 78.9 % of MD, followed by gun shot wound (10.3 %), stabbing (8.5 %), falls (4.3 %), and assaults (4 %). Abdominal and head injuries were more frequent in cases of MD compared with patients admitted to the hospital (33.3 vs. 25.1 % abdominal, 55.6 vs. 29.4 % head; p < 0.001). A greater proportion of MDs were characterized by lack of restraint use (66.7 %) compared to women admitted to the hospital (47.7 %) and women discharged after observation (43.1 %); p = 0.014. ER deaths had more negative base excess scores than women who were admitted or discharged (-14 vs. -3 vs. -2; p < 0.001), lower blood pH values (6.96 vs. 7.40 vs. 7.44; p < 0.001), greater Injury Severity Scores (ISS) (44.4 vs. 11.49 vs. 2.66; p < 0.001), and lower Revised Trauma Scores (RTS) (0.5 vs. 7.49 vs. 7.83; p < 0.001). Lack of restraint use in the pregnant population is associated with increased MD. Although not validated in the pregnant population, the ISS and RTS were associated with maternal mortality outcomes.

Prevalence and determinants of unintended pregnancy among pregnant woman attending ANC at Gelemso General Hospital, Oromiya Region, East Ethiopia: a facility based cross-sectional study.

PubMed

Mohammed, Faiza; Musa, Abdulbasit; Amano, Abdella

2016-08-17

Unintended pregnancy is among the major public health problems that predispose women to maternal death and illness mainly through unsafe abortion and poor maternity care. The level of unintended pregnancy is high in developing countries. Hence, the purpose of this study is to assess the prevalence of unintended pregnancy and the associated factors among pregnant woman attending antenatal care at Gelemso General Hospital, East Ethiopia. A facility-based cross-sectional study was conducted from January 10 to April 13, 2015 among women who had attended antenatal care at Gelemso General Hospital. A systematic random sampling technique was used to select a sample of 413 participants. Data were collected via face-to-face interview using a structured and pre-tested questionnaire. Bivariate and multivariate analyses were made to check the associations among the variables and to control the confounding factors. Out of the 413 pregnancies, 112 (27.1 %) were unintended of which 90(21.9 %) were mistimed, and 22(5.2 %) were unwanted. Multivariate analysis revealed that single, divorced/widowed marital statuses, having more than 2 children, and having no awareness of contraception were significantly associated with unintended pregnancy. Over a quarter of women had an unintended pregnancy, a rate which is lower than previously reported. Designing and implementing strategies that address contraceptive needs of unmarried, divorced and widowed women, creating awareness of contraceptives at community level and reinforcing postnatal contraceptive counseling to all mothers giving birth at health institution is recommended to reduce the rate of the unintended pregnancy among parous women.

Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery.

PubMed

Lykke, Jacob A; Langhoff-Roos, Jens; Lockwood, Charles J; Triche, Elizabeth W; Paidas, Michael J

2010-07-01

The combined effects of preterm delivery, small-for-gestational-age offspring, hypertensive disorders of pregnancy, placental abruption and stillbirth on early maternal death from cardiovascular causes have not previously been described in a large cohort. We investigated the effects of pregnancy complications on early maternal death in a registry-based retrospective cohort study of 782 287 women with a first singleton delivery in Denmark 1978-2007, followed for a median of 14.8 years (range 0.25-30.2) accruing 11.6 million person-years. We employed Cox proportional hazard models of early death from cardiovascular and non-cardiovascular causes following preterm delivery, small-for-gestational-age offspring and hypertensive disorders of pregnancy. We found that preterm delivery and small-for-gestational-age were both associated with subsequent death of mothers from cardiovascular and non-cardiovascular causes. Severe pre-eclampsia was associated with death from cardiovascular causes only. There was a less than additive effect on cardiovascular mortality hazard ratios with increasing number of pregnancy complications: preterm delivery 1.90 [95% confidence intervals 1.49, 2.43]; preterm delivery and small-for-gestational-age offspring 3.30 [2.25, 4.84]; preterm delivery, small-for-gestational-age offspring and pre-eclampsia 3.85 [2.07, 7.19]. Thus, we conclude that, separately and combined, preterm delivery and small-for-gestational-age are strong markers of early maternal death from both cardiovascular and non-cardiovascular causes, while hypertensive disorders of pregnancy are markers of early death of mothers from cardiovascular causes.

Socio-Ecological Factors Affecting Pregnant Women's Anemia Status in Freetown, Sierra Leone

ERIC Educational Resources Information Center

M'Cormack, Fredanna; Drolet, Judy

2012-01-01

Background: Sierra Leone has high maternal mortality. Socio-ecological factors are considered contributing factors to this high mortality. Anemia is considered to be a direct cause of 4% of maternal deaths and an indirect cause of 20-40% of maternal deaths. Purpose: The current study explores socio-ecological contributing factors to the anemia…

The impact of targeted subsidies for facility-based delivery on access to care and equity - evidence from a population-based study in rural Burkina Faso.

PubMed

De Allegri, Manuela; Ridde, Valéry; Louis, Valérie R; Sarker, Malabika; Tiendrebéogo, Justin; Yé, Maurice; Müller, Olaf; Jahn, Albrecht

2012-11-01

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P<0.001). The utilization gap across socio-economic quintiles, however, remained unchanged. The amount received for all services associated with births decreased by 67 per cent (P<0.001), but women continued to pay on average 1423 CFA (\\[euro]1=655 CFA), about 500 CFA more than the set tariff of 900 CFA. Our findings indicate the operational effectiveness of the policy in increasing the use of facility-based delivery services for women. The potential to reduce maternal mortality substantially has not yet been assessed by health outcome measures of neonatal and maternal mortality.

Indirect cost of maternal deaths in the WHO African Region in 2010.

PubMed

Kirigia, Joses Muthuri; Mwabu, Germano Mwige; Orem, Juliet Nabyonga; Muthuri, Rosenabi Deborah Karimi

2014-08-31

An estimated 147,741 maternal deaths occurred in 2010 in 45 of the 47 countries in the African Region of the World Health Organization (WHO). The objective of this study was to estimate the indirect cost of maternal deaths in the Region to provide data for use in advocacy for increased domestic and external investment in multisectoral policy interventions to curb maternal mortality. This study used the cost-of-illness method to estimate the indirect cost of maternal mortality, i.e. the loss in non-health gross domestic product (GDP) attributable to maternal deaths. Estimates on maternal mortality for 2010 from Trends in maternal mortality: 1990 to 2010 published by WHO, UNICEF, UNFPA and the World Bank were used in these calculations. Values for future non-health GDP lost were converted into their present values by applying a 3% discount rate. One-way sensitivity analysis at 5% and 10% discount rates assessed the impact on non-health GDP loss. Indirect cost analysis was undertaken for the countries, categorized under three income groups. Group 1 consisted of nine high and upper middle income countries, Group 2 of 12 lower middle income countries, and Group 3 of 26 low income countries. Estimates for Seychelles in Group 1 and South Sudan in Group 3 were not provided in the source used. The 147,741 maternal deaths that occurred in 45 countries in the African Region in 2010 resulted in a total non-health GDP loss of Int$ 4.5 billion (PPP). About 24.5% of the loss was in Group 1 countries, 44.9% in Group 2 countries and 30.6% in Group 3 countries. This translated into losses in non-health GDP of Int$ 139,219, Int$ 35,440 and Int$ 16,397 per maternal death, respectively, for the three groups. Using discount rates of 5% and 10% reduced the total non-health GDP loss by 19.1% and 47.7%, respectively. Maternal mortality is responsible for a noteworthy level of non-health GDP loss among the countries in the African Region. There is urgent need, therefore, to increase domestic and external investment to scale up coverage of existing cost-effective, multisectoral women's health interventions to reduce maternal morbidity and mortality.

"Once the delivery is done, they have finished": a qualitative study of perspectives on postnatal care referrals by traditional birth attendants in Ebonyi state, Nigeria.

PubMed

Chukwuma, Adanna; Mbachu, Chinyere; Cohen, Jessica; Bossert, Thomas; McConnell, Margaret

2017-12-19

While 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers. This study collected qualitative data using focus group discussions involving 28 female health workers, TBAs, and TBA delivery clients. The study conceptual framework drew on constructs in Fishbein and Ajzen's theory of reasoned action onto which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. We analyzed the transcribed data thematically, and linked themes to the study conceptual framework in the discussion to explain variation in TBA referral behavior across the maternal continuum, from the antenatal to postnatal period. Differences in TBA referral before, during, and after delivery appear to reflect the TBAs understanding of the added value of skilled care for the client and the TBA, as well as the TBA's perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBAs in routine postnatal care referrals to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers. Thus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. Further research is needed on the interactions between postnatal maternal complications, TBA referral behavior, and maternal perception of TBA competence.

Background rates of adverse pregnancy outcomes for assessing the safety of maternal vaccine trials in sub-Saharan Africa.

PubMed

Orenstein, Lauren A V; Orenstein, Evan W; Teguete, Ibrahima; Kodio, Mamoudou; Tapia, Milagritos; Sow, Samba O; Levine, Myron M

2012-01-01

Maternal immunization has gained traction as a strategy to diminish maternal and young infant mortality attributable to infectious diseases. Background rates of adverse pregnancy outcomes are crucial to interpret results of clinical trials in Sub-Saharan Africa. We developed a mathematical model that calculates a clinical trial's expected number of neonatal and maternal deaths at an interim safety assessment based on the person-time observed during different risk windows. This model was compared to crude multiplication of the maternal mortality ratio and neonatal mortality rate by the number of live births. Systematic reviews of severe acute maternal morbidity (SAMM), low birth weight (LBW), prematurity, and major congenital malformations (MCM) in Sub-Saharan African countries were also performed. Accounting for the person-time observed during different risk periods yields lower, more conservative estimates of expected maternal and neonatal deaths, particularly at an interim safety evaluation soon after a large number of deliveries. Median incidence of SAMM in 16 reports was 40.7 (IQR: 10.6-73.3) per 1,000 total births, and the most common causes were hemorrhage (34%), dystocia (22%), and severe hypertensive disorders of pregnancy (22%). Proportions of liveborn infants who were LBW (median 13.3%, IQR: 9.9-16.4) or premature (median 15.4%, IQR: 10.6-19.1) were similar across geographic region, study design, and institutional setting. The median incidence of MCM per 1,000 live births was 14.4 (IQR: 5.5-17.6), with the musculoskeletal system comprising 30%. Some clinical trials assessing whether maternal immunization can improve pregnancy and young infant outcomes in the developing world have made ethics-based decisions not to use a pure placebo control. Consequently, reliable background rates of adverse pregnancy outcomes are necessary to distinguish between vaccine benefits and safety concerns. Local studies that quantify population-based background rates of adverse pregnancy outcomes will improve safety assessment of interventions during pregnancy.

A community-based cluster randomized controlled trial (cRCT) to evaluate the impact and operational assessment of "safe motherhood and newborn health promotion package": study protocol.

PubMed

Hoque, Dewan Md Emdadul; Chowdhury, Mohiuddin Ahsanul Kabir; Rahman, Ahmed Ehsanur; Billah, Sk Masum; Bari, Sanwarul; Tahsina, Tazeen; Hasan, Mohammad Mehedi; Islam, Sajia; Islam, Tajul; Mori, Rintaro; Arifeen, Shams El

2018-05-03

Despite considerable progress in reduction of both under-five and maternal mortality in recent decades, Bangladesh is still one of the low and middle income countries with high burden of maternal and neonatal mortality. The primary objective of the current study is to measure the impact of a comprehensive package of interventions on maternal and neonatal mortality. In addition, changes in coverage, quality and utilization of maternal and newborn health (MNH) services, social capital, and cost effectiveness of the interventions will be measured. A community-based, cluster randomized controlled trial design will be adopted and implemented in 30 unions of three sub-districts of Chandpur district of Bangladesh. Every union, the lowest administrative unit of the local government with population of around 20,000-30,000, will be considered a cluster. Based on the baseline estimates, 15 clusters will be paired for random assignment as intervention and comparison clusters. The primary outcome measure is neonatal mortality, and secondary outcomes are coverage of key interventions like ANC, PNC, facility and skilled provider delivery. Baseline, midterm and endline household survey will be conducted to assess the key coverage of interventions. Health facility assessment surveys will be conducted periodically to assess facility readiness and utilization of MNH services in the participating health facilities. The current study is expected to provide essential strong evidences on the impact of a comprehensive package of interventions to the Bangladesh government, and other developmental partners. The study results may help in prioritizing, planning, and scaling-up of Safe Motherhood Promotional interventions in other geographical areas of Bangladesh as well as to inform other developing countries of similar settings. NCT03032276 .

Factors associated with maternal death in an intensive care unit

PubMed Central

Saintrain, Suzanne Vieira; de Oliveira, Juliana Gomes Ramalho; Saintrain, Maria Vieira de Lima; Bruno, Zenilda Vieira; Borges, Juliana Lima Nogueira; Daher, Elizabeth De Francesco; da Silva Jr, Geraldo Bezerra

2016-01-01

Objective To identify factors associated with maternal death in patients admitted to an intensive care unit. Methods A cross-sectional study was conducted in a maternal intensive care unit. All medical records of patients admitted from January 2012 to December 2014 were reviewed. Pregnant and puerperal women were included; those with diagnoses of hydatidiform mole, ectopic pregnancy, or anembryonic pregnancy were excluded, as were patients admitted for non-obstetrical reasons. Death and hospital discharge were the outcomes subjected to comparative analysis. Results A total of 373 patients aged 13 to 45 years were included. The causes for admission to the intensive care unit were hypertensive disorders of pregnancy, followed by heart disease, respiratory failure, and sepsis; complications included acute kidney injury (24.1%), hypotension (15.5%), bleeding (10.2%), and sepsis (6.7%). A total of 28 patients died (7.5%). Causes of death were hemorrhagic shock, multiple organ failure, respiratory failure, and sepsis. The independent risk factors associated with death were acute kidney injury (odds ratio [OR] = 6.77), hypotension (OR = 15.08), and respiratory failure (OR = 3.65). Conclusion The frequency of deaths was low. Acute kidney injury, hypotension, and respiratory insufficiency were independent risk factors for maternal death. PMID:28099637

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia.

PubMed

D'Ambruoso, Lucia; Byass, Peter; Qomariyah, Siti Nurul; Ouédraogo, Moctar

2010-11-01

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach. Copyright © 2010 Elsevier Ltd. All rights reserved.

Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.

PubMed

Sobhy, Soha; Zamora, Javier; Dharmarajah, Kuhan; Arroyo-Manzano, David; Wilson, Matthew; Navaratnarajah, Ramesan; Coomarasamy, Arri; Khan, Khalid S; Thangaratinam, Shakila

2016-05-01

The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries. In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805. 44 studies (632,556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32,149,636 pregnancies and 36,144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8-1·7, I(2)=83%). Anaesthesia accounted for 2·8% (2·4-3·4, I(2)=75%) of all maternal deaths, 3·5% (2·9-4·3, I(2)=79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0-20·7, I(2)=84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2-9·0, I(2)=58%), and perinatal deaths (2·3, 1·2-4·1, I(2)=73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2-15·7, I(2)=92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9-12·6, I(2)=95%) when managed by physician anaesthetists. The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. Ammalife Charity and ELLY Appeal, Bart's Charity. Copyright © 2016 Sobhy et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

The Associations between Types of Ambient PM2.5 and Under-Five and Maternal Mortality in Africa.

PubMed

Owili, Patrick Opiyo; Lien, Wei-Hung; Muga, Miriam Adoyo; Lin, Tang-Huang

2017-03-30

Exploring the effects of different types of PM 2.5 is necessary to reduce associated deaths, especially in low- and middle-income countries (LMICs). Hence we determined types of ambient PM 2.5 before exploring their effects on under-five and maternal mortality in Africa. The spectral derivate of aerosol optical depth (AOD) from Moderate Resolution Imaging Spectroradiometer (MODIS) products from 2000 to 2015 were employed to determine the aerosol types before using Generalized Linear and Additive Mixed-Effect models with Poisson link function to explore the associations and penalized spline for dose-response relationships. Four types of PM 2.5 were identified in terms of mineral dust, anthropogenic pollutant, biomass burning and mixture aerosols. The results demonstrate that biomass PM 2.5 increased the rate of under-five mortality in Western and Central Africa, each by 2%, and maternal mortality in Central Africa by 19%. Anthropogenic PM 2.5 increased under-five and maternal deaths in Northern Africa by 5% and 10%, respectively, and maternal deaths by 4% in Eastern Africa. Dust PM 2.5 increased under-five deaths in Northern, Western, and Central Africa by 3%, 1%, and 10%, respectively. Mixture PM 2.5 only increased under-five deaths and maternal deaths in Western (incidence rate ratio = 1.01, p < 0.10) and Eastern Africa (incidence rate ratio = 1.06, p < 0.01), respectively. The findings indicate the types of ambient PM 2.5 are significantly associated with under-five and maternal mortality in Africa where the exposure level usually exceeds the World Health Organization's (WHO) standards. Appropriate policy actions on protective and control measures are therefore suggested and should be developed and implemented accordingly.

The Associations between Types of Ambient PM2.5 and Under-Five and Maternal Mortality in Africa

PubMed Central

Owili, Patrick Opiyo; Lien, Wei-Hung; Muga, Miriam Adoyo; Lin, Tang-Huang

2017-01-01

Exploring the effects of different types of PM2.5 is necessary to reduce associated deaths, especially in low- and middle-income countries (LMICs). Hence we determined types of ambient PM2.5 before exploring their effects on under-five and maternal mortality in Africa. The spectral derivate of aerosol optical depth (AOD) from Moderate Resolution Imaging Spectroradiometer (MODIS) products from 2000 to 2015 were employed to determine the aerosol types before using Generalized Linear and Additive Mixed-Effect models with Poisson link function to explore the associations and penalized spline for dose-response relationships. Four types of PM2.5 were identified in terms of mineral dust, anthropogenic pollutant, biomass burning and mixture aerosols. The results demonstrate that biomass PM2.5 increased the rate of under-five mortality in Western and Central Africa, each by 2%, and maternal mortality in Central Africa by 19%. Anthropogenic PM2.5 increased under-five and maternal deaths in Northern Africa by 5% and 10%, respectively, and maternal deaths by 4% in Eastern Africa. Dust PM2.5 increased under-five deaths in Northern, Western, and Central Africa by 3%, 1%, and 10%, respectively. Mixture PM2.5 only increased under-five deaths and maternal deaths in Western (incidence rate ratio = 1.01, p < 0.10) and Eastern Africa (incidence rate ratio = 1.06, p < 0.01), respectively. The findings indicate the types of ambient PM2.5 are significantly associated with under-five and maternal mortality in Africa where the exposure level usually exceeds the World Health Organization’s (WHO) standards. Appropriate policy actions on protective and control measures are therefore suggested and should be developed and implemented accordingly. PMID:28358348

New dialogue for the way forward in maternal health: addressing market inefficiencies.

PubMed

McCarthy, Katharine; Ramarao, Saumya; Taboada, Hannah

2015-06-01

Despite notable progress in Millennium Development Goal (MDG) five, to reduce maternal deaths three-quarters by 2015, deaths due to treatable conditions during pregnancy and childbirth continue to concentrate in the developing world. Expanding access to three effective and low-cost maternal health drugs can reduce preventable maternal deaths, if available to all women. However, current failures in markets for maternal health drugs limit access to lifesaving medicines among those most in need. In effort to stimulate renewed action planning in the post-MDG era, we present three case examples from other global health initiatives to illustrate how market shaping strategies can scale-up access to essential maternal health drugs. Such strategies include: sharing intelligence among suppliers and users to better approximate and address unmet need for maternal health drugs, introducing innovative financial strategies to catalyze otherwise unattractive markets for drug manufacturers, and employing market segmentation to create a viable and sustainable market. By building on lessons learned from other market shaping interventions and capitalizing on opportunities for renewed action planning and partnership, the maternal health field can utilize market dynamics to better ensure sustainable and equitable distribution of essential maternal health drugs to all women, including the most marginalized.

Facility-based delivery in the context of Zimbabwe's HIV epidemic--missed opportunities for improving engagement with care: a community-based serosurvey.

PubMed

Buzdugan, Raluca; McCoy, Sandra I; Webb, Karen; Mushavi, Angela; Mahomva, Agnes; Padian, Nancy S; Cowan, Frances M

2015-12-17

In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe. We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing. Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100%). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95% confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95% CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69%). Overall, however 77% of home deliveries occurred among women who had accessed antenatal care and were HIV-tested. Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

Newborn survival in Nepal: a decade of change and future implications.

PubMed

Pradhan, Y V; Upreti, Shyam Raj; Pratap K C, Naresh; K C, Ashish; Khadka, Neena; Syed, Uzma; Kinney, Mary V; Adhikari, Ramesh Kant; Shrestha, Parashu Ram; Thapa, Kusum; Bhandari, Amit; Grear, Kristina; Guenther, Tanya; Wall, Stephen N

2012-07-01

Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly 35,000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal's neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1-59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities.

Candidate-gene association study of mothers with pre-eclampsia, and their infants, analyzing 775 SNPs in 190 genes.

PubMed

Goddard, Katrina A B; Tromp, Gerard; Romero, Roberto; Olson, Jane M; Lu, Qing; Xu, Zhiying; Parimi, Neeta; Nien, Jyh Kae; Gomez, Ricardo; Behnke, Ernesto; Solari, Margarita; Espinoza, Jimmy; Santolaya, Joaquin; Chaiworapongsa, Tinnakorn; Lenk, Guy M; Volkenant, Kimberly; Anant, Madan Kumar; Salisbury, Benjamin A; Carr, Janet; Lee, Min Soeb; Vovis, Gerald F; Kuivaniemi, Helena

2007-01-01

Pre-eclampsia (PE) affects 5-7% of pregnancies in the US, and is a leading cause of maternal death and perinatal morbidity and mortality worldwide. To identify genes with a role in PE, we conducted a large-scale association study evaluating 775 SNPs in 190 candidate genes selected for a potential role in obstetrical complications. SNP discovery was performed by DNA sequencing, and genotyping was carried out in a high-throughput facility using the MassARRAY(TM) System. Women with PE (n = 394) and their offspring (n = 324) were compared with control women (n = 602) and their offspring (n = 631) from the same hospital-based population. Haplotypes were estimated for each gene using the EM algorithm, and empirical p values were obtained for a logistic regression-based score test, adjusted for significant covariates. An interaction model between maternal and offspring genotypes was also evaluated. The most significant findings for association with PE were COL1A1 (p = 0.0011) and IL1A (p = 0.0014) for the maternal genotype, and PLAUR (p = 0.0008) for the offspring genotype. Common candidate genes for PE, including MTHFR and NOS3, were not significantly associated with PE. For the interaction model, SNPs within IGF1 (p = 0.0035) and IL4R (p = 0.0036) gave the most significant results. This study is one of the most comprehensive genetic association studies of PE to date, including an evaluation of offspring genotypes that have rarely been considered in previous studies. Although we did not identify statistically significant evidence of association for any of the candidate loci evaluated here after adjusting for multiple testing using the false discovery rate, additional compelling evidence exists, including multiple SNPs with nominally significant p values in COL1A1 and the IL1A region, and previous reports of association for IL1A, to support continued interest in these genes as candidates for PE. Identification of the genetic regulators of PE may have broader implications, since women with PE are at increased risk of death from cardiovascular diseases later in life.

Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal

PubMed Central

Seward, Nadine; Prost, Audrey; Copas, Andrew; Corbin, Marine; Li, Leah; Colbourn, Tim; Osrin, David; Neuman, Melissa; Azad, Kishwar; Kuddus, Abdul; Nair, Nirmala; Tripathy, Prasanta; Manandhar, Dharma; Costello, Anthony; Cortina-Borja, Mario

2015-01-01

Background Globally, puerperal sepsis accounts for an estimated 8–12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries. Methods We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses. Results Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28–0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62–2.56). Conclusions Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported. PMID:26295838

Grandmultiparity: outcome of delivery in a tertiary hospital in southern Nigeria.

PubMed

Abasiattai, Aniekan M; Utuk, Ntiense M; Udoma, Edem J; Umoh, Augustine V

2011-01-01

Grandmultiparity is traditionally associated with increased risk of complications during pregnancy and delivery. Reports from developed countries where obstetric facilities are excellent and the standard ofperinatal care is high indicate that currently, obstetric complications among grandmultipara are now independently associated with progressive maternal age. In Nigeria and other developing nations however, grandmultiparity still contributes a significant proportion of the obstetric population. The aim of this study is to evaluate the outcome of delivery of grandmultiparous patients at the University of Uyo Teaching Hospital. The case records of all grandmultiparous patients who delivered at the University of Uyo Teaching Hospital, Uyo over a six-year period were studied. Grandmultiparous women constituted 6.4% of the parturients who delivered in the hospital during the study period. Their ages ranged from 20-45 years with majority (71.5%) being 30-39 years. Majority (77.9%) were para 5 and 6 and 326 (80.1%) of the patients booked and received antenatal care in the hospital. Majority of the booked patients (79.8%) initiated antenatal care after 32 weeks of gestation while all the unbooked patients 68 (16.7%) and the antenatal clinic defaulters 8 (2.0%) were brought from unorthodox health facilities when they developed obstetric complications. Two hundred and forty three patients (59.7%) had spontaneous vaginal delivery, 15 (3.7%) of the patients had laparotomy for ruptured uterus and out of these ten of them (66.7%) had a subtotal abdominal hysterectomy while five (33.4%) had uterine repair and bilateral tubal ligation. The perinatal mortality rate was 128/1000 births. There were three maternal deaths, two from eclampsia while one followed postpartum haemorrhage resulting in a maternal mortality rate of 7.4/1000. The prevalence of grandmultiparity in our centre is relatively low. It is, however, associated with high perinatal and maternal morbidity and mortality. We advocate widespread community enlightenment on the importance of limitation of family size and number of child births. There is need for community based studies in our environment accessing the knowledge and attitude of women with high parity towards contraception.

The role of confidential enquiries in the reduction of maternal mortality and alternatives to this approach.

PubMed

Cook, R

1989-09-01

The aim of confidential enquiries into maternal deaths is to identify weaknesses in the maternal health care system with a view to remedying them. The method of confidential enquiry is explained using the British system as an example. The reasons why this apparently useful practice is not more widely adopted can in some countries include fears of litigation or lack of trust in confidentiality. Alternative approaches to maternal death audit are discussed.

Communication about HIV and death: Maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa.

PubMed

Rochat, Tamsen J; Mitchell, Joanie; Lubbe, Anina M; Stein, Alan; Tomlinson, Mark; Bland, Ruth M

2017-01-01

Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health. HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6-10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1-2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline. Children's questions were grouped into three themes: 'threats'; 'implications' and 'clarifications'. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being "frightened" (AOR 6.57 [CI 2.75, 15.70] p=<0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β -0.096 SE1.366 t = -0.07 p = 0.944). The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report. In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Health system and community level interventions for improving antenatal care coverage and health outcomes

PubMed Central

Mbuagbaw, Lawrence; Medley, Nancy; Darzi, Andrea J; Richardson, Marty; Habiba Garga, Kesso; Ongolo-Zogo, Pierre

2015-01-01

Background The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy. This review focused on community-based interventions and health systems-related interventions. Objectives To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no intervention We found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no intervention We found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventions There was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria. Authors' conclusions Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities. PLAIN LANGUAGE SUMMARY Health system and community level interventions for improving antenatal care coverage and health outcomes What is the issue? The World Health Organization recommends at least four antenatal visits for all pregnant women. Almost half of pregnant women worldwide miss out on this level of care, and this is more problematic in low- and middle-income countries. Why is this important? Healthcare during pregnancy is a priority because poor antenatal attendance is associated with delivery of low birthweight babies and more newborn deaths. Antenatal care also provides opportunity for nutritional and health checks, such as whether a woman has a disease like malaria or has been exposed to infectious diseases such as HIV (human immunodeficiency virus) or syphilis. What evidence did we find? We reviewed randomised controlled trials that tested ways to improve the uptake of antenatal care during pregnancy. Some trials tested community-based interventions (media campaigns, education on self and infant care or financial incentives for pregnant women to attend antenatal care), while other trials looked at health systems interventions (home visits for pregnant women or provision of equipment for clinics). We included 34 trials with approximately 400,000 women. Most trials took place in low- and middle-income countries, and most trials were conducted in a way that made us feel confident about trusting the published reports. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. The quality rating (high, moderate or low) shows our level of confidence that the result is robust and meaningful. Trials comparing one intervention with no intervention Single interventions only marginally improved the numbers of women attending four antenatal visits (high quality). Interventions did not improve rates of maternal death (low quality), baby deaths (moderate quality) or low birthweight (high quality). Even so, interventions led to modest improvements in the number of women who had at least one antenatal visit (moderate quality) and who delivered in a health facility (high quality). The number of women who received intermittent preventive treatment for malaria was not reported. Trials comparing two or more interventions with no intervention Combined interventions did not improve the number of women with four or more visits (low quality), or reduce maternal deaths (moderate quality). Nor did it increase the number of women who delivered in a health facility (moderate quality). However, more women who received combined interventions had one or more antenatal visits (moderate quality); there were also fewer baby deaths (moderate quality) and fewer low birthweight babies (moderate quality). The number of women who received intermittent preventive treatment for malaria was not reported. We found no evidence that trials of community interventions worked differently from trials of health systems interventions. Trials comparing one intervention with another intervention - there were no trials for this comparison. Trials comparing one intervention with a combination of interventions - There was no difference in the number of women attending four or more antenatal visits (and at least one visit), maternal deaths, baby deaths, the number of deliveries in a health facility or the number of women who received intermittent preventive treatment for malaria. What does this mean? Single interventions may improve antenatal care coverage (women attending at least one visit and women attending four or more visits) and encourage women to give birth to their babies in health facilities. Combined interventions may also improve antenatal care coverage (at least one visit), reduce baby deaths and reduce the number of babies born with low birthweight. We recommend that further studies of pregnant women and women in their reproductive years use combinations of interventions to maximise impact and look at outcomes that are important to the women themselves, such as maternal and baby deaths or ill health and the use of healthcare services. PMID:26621223

U.S. Maternally Linked Birth Records May Be Biased for Hispanics and Other Population Groups

PubMed Central

LEISS, JACK K.; GILES, DENISE; SULLIVAN, KRISTIN M.; MATHEWS, RAHEL; SENTELLE, GLENDA; TOMASHEK, KAY M.

2010-01-01

Purpose To advance understanding of linkage error in U.S. maternally linked datasets, and how the error may affect results of studies based on the linked data. Methods North Carolina birth and fetal death records for 1988-1997 were maternally linked (n=1,030,029). The maternal set probability, defined as the probability that all records assigned to the same maternal set do in fact represent events to the same woman, was used to assess differential maternal linkage error across race/ethnic groups. Results Maternal set probabilities were lower for records specifying Asian or Hispanic race/ethnicity, suggesting greater maternal linkage error. The lower probabilities for Hispanics were concentrated in women of Mexican origin who were not born in the United States. Conclusions Differential maternal linkage error may be a source of bias in studies using U.S. maternally linked datasets to make comparisons between Hispanics and other groups or among Hispanic subgroups. Methods to quantify and adjust for this potential bias are needed. PMID:20006273

Poor Quality for Poor Women? Inequities in the Quality of Antenatal and Delivery Care in Kenya.

PubMed

Sharma, Jigyasa; Leslie, Hannah H; Kundu, Francis; Kruk, Margaret E

2017-01-01

Quality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty. We assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty. A total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care. The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas.

Poor Quality for Poor Women? Inequities in the Quality of Antenatal and Delivery Care in Kenya

PubMed Central

Sharma, Jigyasa; Leslie, Hannah H.; Kundu, Francis; Kruk, Margaret E.

2017-01-01

Background Quality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty. Methods We assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty. Results A total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care. Conclusion The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas. PMID:28141840

Wealth and antenatal care use: implications for maternal health care utilisation in Ghana

PubMed Central

2012-01-01

The study investigates the effect of wealth on maternal health care utilization in Ghana via its effect on Antenatal care use. Antenatal care serves as the initial point of contact of expectant mothers to maternal health care providers before delivery. The study is pivoted on the introduction of the free maternal health care policy in April 2005 in Ghana with the aim of reducing the financial barrier to the use of maternal health care services, to help reduce the high rate of maternal deaths. Prior to the introduction of the policy, studies found wealth to have a positive and significant influence on the use of Antenatal care. It is thus expected that with the policy, wealth should not influence the use of maternal health care significantly. Using secondary data from the 2008 Ghana Demographic and Health survey, the results have revealed that wealth still has a significant influence on adequate use of Antenatal care. Education, age, number of living children, transportation and health insurance are other factors that were found to influence the use of Antenatal care in Ghana. There also exist considerable variations in the use of Antenatal care in the geographical regions and between the rural and urban dwellers. It is recommended that to improve the use of Antenatal care and hence maternal health care utilization, some means of support is provided especially to women within the lowest wealth quintiles, like the provision and availability of recommended medication at the health center; secondly, women should be encouraged to pursue education to at least the secondary level since this improves their use of maternal health services. Policy should also target mothers who have had the experience of child birth on the need to use adequate Antenatal care for each pregnancy, since these mothers tend to use less antenatal care for subsequent pregnancies. The regional disparities found may be due to inaccessibility and unavailability of health facilities and services in the rural areas and in some of the regions. The government and other service providers (NGOs, religious institutions and private providers) may endeavor to improve on the distribution of health facilities, human resources, good roads and necessary infrastructure among other things in order to facilitate easy access to health care providers especially for the rural dwellers. PMID:22866869

Wealth and antenatal care use: implications for maternal health care utilisation in Ghana.

PubMed

Arthur, Eric

2012-08-06

The study investigates the effect of wealth on maternal health care utilization in Ghana via its effect on Antenatal care use. Antenatal care serves as the initial point of contact of expectant mothers to maternal health care providers before delivery. The study is pivoted on the introduction of the free maternal health care policy in April 2005 in Ghana with the aim of reducing the financial barrier to the use of maternal health care services, to help reduce the high rate of maternal deaths. Prior to the introduction of the policy, studies found wealth to have a positive and significant influence on the use of Antenatal care. It is thus expected that with the policy, wealth should not influence the use of maternal health care significantly. Using secondary data from the 2008 Ghana Demographic and Health survey, the results have revealed that wealth still has a significant influence on adequate use of Antenatal care. Education, age, number of living children, transportation and health insurance are other factors that were found to influence the use of Antenatal care in Ghana. There also exist considerable variations in the use of Antenatal care in the geographical regions and between the rural and urban dwellers. It is recommended that to improve the use of Antenatal care and hence maternal health care utilization, some means of support is provided especially to women within the lowest wealth quintiles, like the provision and availability of recommended medication at the health center; secondly, women should be encouraged to pursue education to at least the secondary level since this improves their use of maternal health services. Policy should also target mothers who have had the experience of child birth on the need to use adequate Antenatal care for each pregnancy, since these mothers tend to use less antenatal care for subsequent pregnancies. The regional disparities found may be due to inaccessibility and unavailability of health facilities and services in the rural areas and in some of the regions. The government and other service providers (NGOs, religious institutions and private providers) may endeavor to improve on the distribution of health facilities, human resources, good roads and necessary infrastructure among other things in order to facilitate easy access to health care providers especially for the rural dwellers.

Maternal morbidity: Neglected dimension of safe motherhood in the developing world

PubMed Central

Hardee, Karen; Gay, Jill; Blanc, Ann K.

2012-01-01

In safe motherhood programming in the developing world, insufficient attention has been given to maternal morbidity, which can extend well beyond childbirth. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity. Maternal morbidity adversely affects families, communities and societies. Maternal morbidity has multiple causes, with duration ranging from acute to chronic, severity ranging from transient to permanent and with a range of diagnosis and treatment options. This article addresses six selected relatively neglected aspects of maternal morbidity to illustrate the range of acute and chronic morbidities that can affect women related to pregnancy and childbearing that are prevalent in developing countries: anaemia, maternal depression, infertility, fistula, uterine rupture and scarring and genital and uterine prolapse. Based on this review, recommendations to reduce maternal morbidity include: expand the focus of safe motherhood to explicitly include morbidity; improve data on incidence and prevalence of maternal morbidity; link mortality and morbidity outcomes and programming; increase access to facility- and community-based maternal health care and reproductive health care; and address the antecedents to poor maternal health through a lifecycle approach. PMID:22424546

INEQUITY ISSUES AND MOTHERS' PREGNANCY, DELIVERY AND EARLY-AGE SURVIVAL EXPERIENCES IN ENDE DISTRICT, INDONESIA.

PubMed

Pardosi, Jerico Franciscus; Parr, Nick; Muhidin, Salut

2015-11-01

Indonesia's infant mortality rates are among the highest in South-East Asia, and there are substantial variations between its sub-national regions. This qualitative study aims to explore early mortality-related health service provision and gender inequity issues based on mothers' pregnancy, delivery and early-age survival experience in Ende district, Nusa Tenggara Timur province. Thirty-two mothers aged 18-45 years with at least one birth in the previous five years were interviewed in depth in May 2013. The results show most mothers have little knowledge about the danger signs for a child's illness. Mothers with early-age deaths generally did not know the cause of death. Very few mothers had received adequate information on maternal and child health during their antenatal and postnatal visits to the health facility. Some mothers expressed a preference for using a traditional birth attendant, because of their ready availability and the more extensive range of support services they provide, compared with local midwives. Unprofessional attitudes displayed by midwives were reported by several mothers. As elsewhere in Indonesia, the power of health decision-making lies with the husband. Policies aimed at elevating mothers' roles in health care decision-making are discussed as measures that would help to improve early-age survival outcomes. Widening the public health insurance distribution, especially among poorer mothers, and equalizing the geographical distribution of midwives and health facilities are recommended to tackle geographical inequities and to increase early-age survival in Ende district.

Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use

PubMed Central

O'Connor, Katherine; Kim, Sunkyung; Kelley, Maureen; Odhiambo, Aloyce; Faith, Sitnah; Otieno, Ronald; Nygren, Benjamin; Kamb, Mary; Quick, Robert

2017-01-01

Reducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9–4.5), health facility delivery (OR = 5.3, 95% CI = 3.4–8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9–4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1–2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5–7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5–4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0–2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women. PMID:28193744

Assessing the Evidence for Maternal Pertussis Immunization: A Report From the Bill & Melinda Gates Foundation Symposium on Pertussis Infant Disease Burden in Low- and Lower-Middle-Income Countries

PubMed Central

Sobanjo-ter Meulen, Ajoke; Duclos, Philippe; McIntyre, Peter; Lewis, Kristen D. C.; Van Damme, Pierre; O'Brien, Katherine L.; Klugman, Keith P.

2016-01-01

Implementation of effective interventions has halved maternal and child mortality over the past 2 decades, but less progress has been made in reducing neonatal mortality. Almost 45% of under-5 global mortality now occurs in infants <1 month of age, with approximately 86% of neonatal deaths occurring in low- and lower-middle-income countries (LMICs). As an estimated 23% of neonatal deaths globally are due to infectious causes, maternal immunization (MI) is one intervention that may reduce mortality in the first few months of life, when direct protection often relies on passively transmitted maternal antibodies. Despite all countries including pertussis-containing vaccines in their routine childhood immunization schedules, supported through the Expanded Programme on Immunization, pertussis continues to circulate globally. Although based on limited robust epidemiologic data, current estimates derived from modeling implicate pertussis in 1% of under-5 mortality, with infants too young to be vaccinated at highest risk of death. Pertussis MI programs have proven effective in reducing infant pertussis mortality in high-income countries using tetanus-diphtheria-acellular pertussis (Tdap) vaccines in their maternal and infant programs; however, these vaccines are cost-prohibitive for routine use in LMICs. The reach of antenatal care programs to deliver maternal pertussis vaccines, particularly with respect to infants at greatest risk of pertussis, needs to be further evaluated. Recognizing that decisions on the potential impact of pertussis MI in LMICs need, as a first step, robust contemporary mortality data for early infant pertussis, a symposium of global key experts was held. The symposium reviewed current evidence and identified knowledge gaps with respect to the infant pertussis disease burden in LMICs, and discussed proposed strategies to assess the potential impact of pertussis MI. PMID:27838664

Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities.

PubMed

Bhutta, Zulfiqar A; Hafeez, Assad; Rizvi, Arjumand; Ali, Nabeela; Khan, Amanullah; Ahmad, Faatehuddin; Bhutta, Shereen; Hazir, Tabish; Zaidi, Anita; Jafarey, Sadequa N

2013-06-22

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367,900 deaths (15,900 maternal, 169,000 newborn, 183,000 child deaths) and 49% of an estimated 180,000 stillbirths could be prevented in 2015. Copyright © 2013 Elsevier Ltd. All rights reserved.

Does maternal birth outcome differentially influence the occurrence of infant death among African Americans and European Americans?

PubMed

Masho, Saba W; Archer, Phillip W

2011-11-01

The United States continues to have one of the highest infant mortality rates (IMR). Although studies have examined the association between maternal and infant birth outcomes, few studies have examined the impact of maternal birth outcome on infant mortality. This study was designed to examine the influence of maternal low birth weight and preterm birth on infant mortality. The 1997-2007 Virginia birth and infant death registry was analyzed. The infant birth and death data was linked to maternal birth registry data using the mother's maiden name and date of birth. From the mother's birth registry data, the grandmother's demographic and pregnancy history was obtained. Logistic regression modeling was used to estimate adjusted odds ratios and their 95% confidence intervals. There was a statistically significant association between maternal birth outcome and subsequent infant mortality. Infants born from a mother who was low birth weight were 2.3 times more likely to have an infant die within the first year of life. Similarly, infants born from a mother born preterm were 2.2 times more likely to have an infant die. Stratification by race showed that there was no statistical association between maternal birth weight and infant death among Whites. However, a strong association was observed among Blacks. Maternal birth outcomes may be an important indicator for infant mortality. Future longitudinal studies are needed to understand the underlying cause of these associations.

Effects of the West Africa Ebola Virus Disease on Health-Care Utilization – A Systematic Review

PubMed Central

Brolin Ribacke, Kim J.; Saulnier, Dell D.; Eriksson, Anneli; von Schreeb, Johan

2016-01-01

Significant efforts were invested in halting the recent Ebola virus disease outbreak in West Africa. Now, studies are emerging on the magnitude of the indirect health effects of the outbreak in the affected countries, and the aim of this study is to systematically assess the results of these publications. The methodology for this review adhered to the Prisma guidelines for systematic reviews. A total of 3354 articles were identified for screening, and while 117 articles were read in full, 22 studies were included in the final review. Utilization of maternal health services decreased during the outbreak. The number of cesarean sections and facility-based deliveries declined and followed a similar pattern in Guinea, Liberia, and Sierra Leone. A change in the utilization of antenatal and postnatal care and family planning services was also seen, as well as a drop in utilization of children’s health services, especially in terms of vaccination coverage. In addition, the uptake of HIV/AIDS and malaria services, general hospital admissions, and major surgeries decreased as well. Interestingly, it was the uptake of health service provision by the population that decreased, rather than the volume of health service provision. Estimates from the various studies suggest that non-Ebola morbidity and mortality have increased after the onset of the outbreak in Sierra Leone, Guinea, and Liberia. Reproductive, maternal, and child health services were especially affected, and the decrease in facility deliveries, cesarean sections, and volume of antenatal and postnatal care visits might have significant adverse effects on maternal and newborn health. The impact of Ebola stretches far beyond Ebola cases and deaths. This review indicates that indirect health service effects are substantial and both short and long term, and highlights the importance of support to maintain routine health service delivery and the maintenance of vaccination programs as well as preventative and curative malaria programs, both in general but especially in times of a disaster. PMID:27777926

Six year trend of neonatal septicaemia in a large Malaysian maternity hospital.

PubMed

Boo, N Y; Chor, C Y

1994-02-01

A study carried out in the Maternity Hospital, Kuala Lumpur over a 6 year period from 1986 to 1991, showed that the annual rates of septicaemia ranged from 5.2 to 10.2/100 admissions. Septicaemia accounted for between 11.0 to 30.4% of all neonatal deaths. The case fatality ratios ranged from 23.0 to 52.2%, being highest in 1989 when basic facilities were compromised. Low birthweight neonates accounted for 55.5% of those with septicaemia. The most common causative organisms were Staphylococcus epidermidis and Staphylococcus aureus in 1986 and 1987, but from 1988 Klebsiella species became the most common. More than 50% of neonatal septicaemia occurred after the age of 2 days. The results of the study demonstrated the dynamism of infection control: when control measures introduced earlier were not sustained, outbreaks of nosocomial infection recurred or worsened.

[Pregnancy and delivery in western Africa. High risk motherhood].

PubMed

Prual, A

1999-06-01

According to the World Health Organization, 585,000 women die each year from a pregnancy-related cause, 99% of whom are from developing countries. The first International Conference on Safe Motherhood in 1987 sensitized the world community to this drama. Ever since, maternal mortality and its medical causes are better known. The maternal mortality ratio is highest in West Africa (1,020 maternal deaths per 100,000 live borns) when it is 27/100,000 in industrialized countries. Direct obstetric causes account for 80% of the deaths: hemorrhage, infection, dystocia, hypertension and abortion. Indirect causes are essentially anemia, malaria, hepatitis C and AIDS. Severe maternal morbidity is 6 to 10 times more frequent than maternal mortality but it also leads to handicaps which end up often in women's social rejection. However, WHO estimates that 95% of these deaths and handicaps are avoidable, and at a low cost.

Maternal Near Miss According to World Health Organization Classification Among Women with a Hydatidiform Mole: Experience at the New England Trophoblastic Disease Center, 1994-2013.

PubMed

Sun, Sue Yazaki; Goldstein, Donald P; Bernstein, Marilyn R; Horowitz, Neil S; Mattar, Rosiane; Maestá, Izildinha; Braga, Antonio; Berkowitz, Ross S

2016-01-01

To investigate the frequency of potentially life-threatening conditions (PLTCs) and maternal near misses (MNMs) at the New England Trophoblastic Disease Center (NETDC) in recent years, when there has been earlier diagnosis of molar pregnancy. This study included patients with molar pregnancy at the NETDC between 1994 and 2013. Clinical and pathologic reports were reviewed. PLTC and MNM criteria and maternal deaths were searched in medical records using the World Health Organization criteria and classification. We identified 375 patients with molar pregnancy and no patient developed a MNM or maternal death. Only 6 (1.6%) had PLTCs (hemorrhage with hemodynamic instability, severe preeclampsia, respiratory distress, blood transfusion, and ICU admission). We observed a low rate of PLTC and no cases of MNMs or maternal deaths related to molar pregnancy, likely due to earlier diagnosis at the NETDC in recent years.

Use of hospital data for Safe Motherhood programmes in south Kalimantan, Indonesia.

PubMed

Ronsmans, C; Achadi, E; Sutratikto, G; Zazri, A; McDermott, J

1999-07-01

The evaluation of Safe Motherhood programmes has been hampered by difficulties in measuring the preferred outcomes of maternal mortality and morbidity. The need for adequate indicators has led researchers and programme managers alike to resort to indicators of utilization and quality of health services. In this study we assess the magnitude of four indicators of use of essential obstetric care (EOC) and one indicator of quality of care in health facilities in three districts in South Kalimantan, Indonesia. The general picture which emerges for South Kalimantan is that the use of obstetric services is low. Even in the more urban district of Banjar where facility-based coverage is highest, fewer than 14% of all deliveries take place in an EOC facility, 2% of expected births are admitted to such a facility with a major obstetric intervention (MOI), and 1% of expected births have an MOI for an absolute maternal indication. The use of facility-based EOC is consistently lower in Barito Kuala compared to the other districts, and the differences persist regardless of the indicators used. In this setting with low utilization rates, general rates of utilization of EOC facilities seem to be as satisfactory an indicator of relative access to EOC as more elaborate indicators specifying the reasons for admission. The inequalities in access to care revealed by the various indicators of use of EOC services may prove to be a more powerful stimulus for change than the widely reported and highly inaccurate accounts of the high levels of maternal mortality.

Death Awareness, Maternal Separation Anxiety, and Attachment Style among First-Time Mothers--A Terror Management Perspective

ERIC Educational Resources Information Center

Taubman-Ben-Ari, Orit; Katz-Ben-Ami, Liat

2008-01-01

Two studies explored the interplay between death awareness, attachment style, and maternal separation anxiety among first-time mothers of infants aged 3-12 months. In Study 1 (N = 60), a higher accessibility of death-related thoughts was found following induction of thoughts about separation from the infant. In Study 2 (N = 100), a mortality…

A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low- and middle-income countries.

PubMed

Harrison, Margo S; Ali, Sumera; Pasha, Omrana; Saleem, Sarah; Althabe, Fernando; Berrueta, Mabel; Mazzoni, Agustina; Chomba, Elwyn; Carlo, Waldemar A; Garces, Ana; Krebs, Nancy F; Hambidge, K; Goudar, Shivaprasad S; Dhaded, S M; Kodkany, Bhala; Derman, Richard J; Patel, Archana; Hibberd, Patricia L; Esamai, Fabian; Liechty, Edward A; Moore, Janet L; Koso-Thomas, Marion; McClure, Elizabeth M; Goldenberg, Robert L

2015-01-01

This population-based study sought to quantify maternal, fetal, and neonatal morbidity and mortality in low- and middle-income countries associated with obstructed labor, prolonged labor and failure to progress (OL/PL/FTP). A prospective, population-based observational study of pregnancy outcomes was performed at seven sites in Argentina, Guatemala, India (2 sites, Belgaum and Nagpur), Kenya, Pakistan and Zambia. Women were enrolled in pregnancy and delivery and 6-week follow-up obtained to evaluate rates of OL/PL/FTP and outcomes resulting from OL/PL/FTP, including: maternal and delivery characteristics, maternal and neonatal morbidity and mortality and stillbirth. Between 2010 and 2013, 266,723 of 267,270 records (99.8%) included data on OL/PL/FTP with an overall rate of 110.4/1000 deliveries that ranged from 41.6 in Zambia to 200.1 in Pakistan. OL/PL/FTP was more common in women aged <20, nulliparous women, more educated women, women with infants >3500g, and women with a BMI >25 (RR 1.4, 95% CI 1.3 - 1.5), with the suggestion of OL/PL/FTP being less common in preterm deliveries. Protective characteristics included parity of ≥3, having an infant <1500g, and having a BMI <18. Women with OL/PL/FTP were more likely to die within 42 days (RR 1.9, 95% CI 1.4 - 2.4), be infected (RR 1.8, 95% CI 1.5 - 2.2), and have hemorrhage antepartum (RR 2.8, 95% CI 2.1 - 3.7) or postpartum (RR 2.4, 95% CI 1.8 - 3.3). They were also more likely to have a stillbirth (RR 1.6, 95% CI 1.3 - 1.9), a neonatal demise at < 28 days (RR 1.9, 95% CI 1.6 - 2.1), or a neonatal infection (RR 1.2, 95% CI 1.1 - 1.3). As compared to operative vaginal delivery and cesarean section (CS), women experiencing OL/PL/FTP who gave birth vaginally were more likely to become infected, to have an infected neonate, to hemorrhage in the antepartum and postpartum period, and to die, have a stillbirth, or have a neonatal demise. Women with OL/PL/FTP were far more likely to deliver in a facility and be attended by a physician or other skilled provider than women without this diagnosis. Women with OL/PL/FTP in the communities studied were more likely to be primiparous, younger than age 20, overweight, and of higher education, with an infant with birthweight of >3500g. Women with this diagnosis were more likely to experience a maternal, fetal, or neonatal death, antepartum and postpartum hemorrhage, and maternal and neonatal infection. They were also more likely to deliver in a facility with a skilled provider. CS may decrease the risk of poor outcomes (as in the case of antepartum hemorrhage), but unassisted vaginal delivery exacerbates all of the maternal, fetal, and neonatal outcomes evaluated in the setting of OL/PL/FTP.

A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low- and middle-income countries

PubMed Central

2015-01-01

Background This population-based study sought to quantify maternal, fetal, and neonatal morbidity and mortality in low- and middle-income countries associated with obstructed labor, prolonged labor and failure to progress (OL/PL/FTP). Methods A prospective, population-based observational study of pregnancy outcomes was performed at seven sites in Argentina, Guatemala, India (2 sites, Belgaum and Nagpur), Kenya, Pakistan and Zambia. Women were enrolled in pregnancy and delivery and 6-week follow-up obtained to evaluate rates of OL/PL/FTP and outcomes resulting from OL/PL/FTP, including: maternal and delivery characteristics, maternal and neonatal morbidity and mortality and stillbirth. Results Between 2010 and 2013, 266,723 of 267,270 records (99.8%) included data on OL/PL/FTP with an overall rate of 110.4/1000 deliveries that ranged from 41.6 in Zambia to 200.1 in Pakistan. OL/PL/FTP was more common in women aged <20, nulliparous women, more educated women, women with infants >3500g, and women with a BMI >25 (RR 1.4, 95% CI 1.3 – 1.5), with the suggestion of OL/PL/FTP being less common in preterm deliveries. Protective characteristics included parity of ≥3, having an infant <1500g, and having a BMI <18. Women with OL/PL/FTP were more likely to die within 42 days (RR 1.9, 95% CI 1.4 – 2.4), be infected (RR 1.8, 95% CI 1.5 – 2.2), and have hemorrhage antepartum (RR 2.8, 95% CI 2.1 – 3.7) or postpartum (RR 2.4, 95% CI 1.8 – 3.3). They were also more likely to have a stillbirth (RR 1.6, 95% CI 1.3 – 1.9), a neonatal demise at < 28 days (RR 1.9, 95% CI 1.6 – 2.1), or a neonatal infection (RR 1.2, 95% CI 1.1 – 1.3). As compared to operative vaginal delivery and cesarean section (CS), women experiencing OL/PL/FTP who gave birth vaginally were more likely to become infected, to have an infected neonate, to hemorrhage in the antepartum and postpartum period, and to die, have a stillbirth, or have a neonatal demise. Women with OL/PL/FTP were far more likely to deliver in a facility and be attended by a physician or other skilled provider than women without this diagnosis. Conclusions Women with OL/PL/FTP in the communities studied were more likely to be primiparous, younger than age 20, overweight, and of higher education, with an infant with birthweight of >3500g. Women with this diagnosis were more likely to experience a maternal, fetal, or neonatal death, antepartum and postpartum hemorrhage, and maternal and neonatal infection. They were also more likely to deliver in a facility with a skilled provider. CS may decrease the risk of poor outcomes (as in the case of antepartum hemorrhage), but unassisted vaginal delivery exacerbates all of the maternal, fetal, and neonatal outcomes evaluated in the setting of OL/PL/FTP. PMID:26063492

Oxytocin for preventing postpartum haemorrhage (PPH) in non-facility birth settings.

PubMed

Pantoja, Tomas; Abalos, Edgardo; Chapman, Evelina; Vera, Claudio; Serrano, Valentina P

2016-04-14

Postpartum haemorrhage (PPH) is the single leading cause of maternal mortality worldwide. Most of the deaths associated with PPH occur in resource-poor settings where effective methods of prevention and treatment - such as oxytocin - are not accessible because many births still occur at home, or in community settings, far from a health facility. Likewise, most of the evidence supporting oxytocin effectiveness comes from hospital settings in high-income countries, mainly because of the need of well-organised care for its administration and monitoring. Easier methods for oxytocin administration have been developed for use in resource-poor settings, but as far as we know, its effectiveness has not been assessed in a systematic review. To assess the effectiveness and safety of oxytocin provided in non-facility birth settings by any way in the third stage of labour to prevent PPH. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov (12 November 2015), and reference lists of retrieved reports. All published, unpublished or ongoing randomised or quasi-randomised controlled trials comparing the administration of oxytocin with no intervention, or usual/standard care for the management of the third stage of labour in non-facility birth settings were considered for inclusion.Quasi-randomised controlled trials and randomised controlled trials published in abstract form only were eligible for inclusion but none were identified. Cross-over trials were not eligible for inclusion in this review. Two review authors independently assessed studies for eligibility, assessed risk of bias and extracted the data using an agreed data extraction form. Data were checked for accuracy. We included one cluster-randomised trial conducted in four rural districts in Ghana that randomised 28 community health officers (CHOs) (serving 2404 potentially eligible pregnant women) to the intervention group and 26 CHOs (serving 3515 potentially eligible pregnant women) to the control group. Overall, the trial had a high risk of bias. CHOs delivered the intervention in the experimental group (injection of 10 IU (international units) of oxytocin in the thigh one minute following birth using a prefilled, auto-disposable syringe). In the control group, CHOs did not provide this prophylactic injection to the women they observed. CHOs had no midwifery skills and did not in any way manage the birth. All other CHO activities (outcome measurement, data collection, and early treatment and referral when necessary) were identical across the control and oxytocin CHOs.Although only one of the nine cases of severe PPH (blood loss greater or equal to 1000 mL) occurred in the oxytocin group, the effect estimate for this outcome was very imprecise and it is uncertain whether the intervention prevents severe PPH (risk ratio (RR) 0.16, 95% confidence interval (CI) 0.02 to 1.30; 1570 women (very low-quality evidence)). Similarly, because of the lack of cases of severe maternal morbidity (e.g. uterine rupture) and maternal deaths, it was not possible to obtain effect estimates for those outcomes (both very low-quality evidence).Oxytocin compared with the control group decreased the incidence of PPH (> 500 mL) in both our unadjusted (RR 0.48, 95% CI 0.28 to 0.81; 1569 women) and adjusted (RR 0.49, 95% CI 0.27 to 0.90; 1174 women (both low-quality evidence)) analyses. There was little or no difference between the oxytocin and control groups on the rates of transfer or referral of the mother to a healthcare facility (RR 0.72, 95% CI 0.34 to 1.56; 1586 women (low-quality evidence)), stillbirths (RR 1.27, 95% CI 0.67 to 2.40; 2006 infants (low-quality evidence)); andearly infant deaths (0 to three days) (RR 1.03, 95% CI 0.35 to 3.07; 1969 infants (low-quality evidence)). There were no cases of needle-stick injury or any other maternal major or minor adverse event or unanticipated harmful event. There were no cases of oxytocin use during labour.There were no data reported for some of this review's secondary outcomes: manual removal of placenta, maternal anaemia, neonatal death within 28 days, neonatal transfer to health facility for advanced care, breastfeeding rates. Similarly, the women's or the provider's satisfaction with the intervention was not reported. It is uncertain if oxytocin administered by CHO in non-facility settings compared with a control group reduces the incidence of severe PPH (>1000 mL), severe maternal morbidity or maternal deaths. However, the intervention probably decreases the incidence of PPH (> 500 mL).The quality of the one trial included in this review was limited because of the risk of attrition and recruitment biases related to limitations in the follow-up of pregnant women in both arms of the trials and some baseline imbalance on the size of babies at birth. Additionally, there was serious imprecision of the effect estimates for most of the primary outcomes mainly because of the size of the trial, very few or no events and CIs around both relative and absolute estimates of effect that include both appreciable benefit and appreciable harm.Although the trial presented data both for primary and secondary outcomes, it seemed to be underpowered to detect differences in the primary outcomes that are the ones more relevant for making judgments about the potential applicability of the intervention in other settings (especially severe PPH).Therefore, taking into account the extreme setting where the intervention was implemented, the limited role of the CHO in the trial and the lack of power for detecting effects on primary (relevant) outcomes, the applicability of the evidence found seems to be rather limited.Further well-executed and adequately-powered randomised controlled trials assessing the effects of using oxytocin in pre-filled injection devices or other new delivery systems (spray-dried ultrafine formulation of oxytocin) on severe PPH are urgently needed. Likewise, other important outcomes like possible adverse events and acceptability of the intervention by mothers and other community stakeholders should also be assessed.

Active management of third stage of labour, post–partum haemorrhage and maternal death rate in the Vanga Health Zone, Province of Bandundu, Democratic Republic of the Congo

PubMed Central

Ngolo, Jean-Robert Musiti; Maniati, Lucie Zikudieka

2010-01-01

ABSTRACT Background Post-partum haemorrhage (PPH) is the single largest cause of maternal death worldwide and a particular burden for developing countries. In Africa, about 33.9% of maternal deaths are due to PPH. In the Democratic Republic of the Congo (DRC), the prevalence of PPH is unknown. PPH can be prevented with active management of the third stage of labour (AMTSL). Objectives To describe the practice of AMTSL in Vanga Health Zone and to calculate the incidence of PPH in Vanga Health Zone. Method An intervention study with post-test-only design was conducted among health maternity wards using a data collection sheet to obtain information. All pregnant women attending Vanga Health maternity wards constituted the study population. Frequencies were determined for variables of interest. Results From April 2007 to March 2008, 6339 deliveries took place at Vanga Health maternity wards, representing 71% of the institutional delivery rate. The number of deliveries realised with the practice of (AMTSL) were 5562; 366 cases of PPH were reported, making an incidence of 5.77%. Three cases of maternal deaths – two of which were related to PPH – were reported during the study period, which means there was a decline of 70% compared with the previous two years. Conclusion The prevalence of PPH has been estimated to be 5.77%; PPH represents the cause of 67% of all maternal deaths. The extension of AMTSL practice, combined with the assurance of better supplies of oxytocin to enhance drug management, is strongly advised/suggested. As a number of births still take place outside the health maternity wards, the introduction of oral misoprostol could be considered a part of AMTSL for use by patients being treated by traditional midwives.

Determinants of use of health facility for childbirth in rural Hadiya zone, Southern Ethiopia.

PubMed

Asseffa, Netsanet Abera; Bukola, Fawole; Ayodele, Arowojolu

2016-11-16

Maternal mortality remains a major global public health concern despite many international efforts. Facility-based childbirth increases access to appropriate skilled attendance and emergency obstetric care services as the vast majority of obstetric complications occur during delivery. The purpose of the study was to determine the proportion of facility delivery and assess factors influencing utilization of health facility for childbirth. A cross-sectional study was conducted in two rural districts of Hadiya zone, southern Ethiopia. Participants who delivered within three years of the survey were selected by stratified random sampling. Trained interviewers administered a pre-tested semi-structured questionnaire. We employed bivariate analysis and logistic regression to identify determinants of facility-based delivery. Data from 751 participants showed that 26.9% of deliveries were attended in health facilities. In bivariate analysis, maternal age, education, husband's level of education, possession of radio, antenatal care, place of recent ANC attended, planned pregnancy, wealth quintile, parity, birth preparedness and complication readiness, being a model family and distance from the nearest health facility were associated with facility delivery. On multiple logistic regression, age, educational status, antenatal care, distance from the nearest health facility, wealth quintile, being a model family, planned pregnancy and place of recent ANC attended were the determinants of facility-based childbirth. Efforts to improve institutional deliveries in the region must strengthen initiatives that promote female education, opportunities for wealth creation, female empowerment and increased uptake of family planning among others. Service related barriers and cultural influences on the use of health facility for childbirth require further evaluation.

Boosting facility deliveries with results-based financing: a mixed-methods evaluation of the government midwifery incentive scheme in Cambodia.

PubMed

Ir, Por; Korachais, Catherine; Chheng, Kannarath; Horemans, Dirk; Van Damme, Wim; Meessen, Bruno

2015-08-15

Increasing the coverage of skilled attendance at births in a health facility (facility delivery) is crucial for saving the lives of mothers and achieving Millennium Development Goal five. Cambodia has significantly increased the coverage of facility deliveries and reduced the maternal mortality ratio in the last decade. The introduction of a nationwide government implemented and funded results-based financing initiative, known as the Government Midwifery Incentive Scheme (GMIS), is considered one of the most important contributors to this. We evaluated GMIS to explore its effects on facility deliveries and the health system. We used a mixed-methods design. An interrupted time series model was applied, using routine longitudinal data on reported deliveries between 2006 and 2011 that were extracted from the health information system. In addition, we interviewed 56 key informants and performed 12 focus group discussions with 124 women who had given birth (once or more) since 2006. Findings from the quantitative data were carefully interpreted and triangulated with those from qualitative data. We found that facility deliveries have tripled from 19% of the estimated number of births in 2006 to 57% in 2011 and this increase was more substantial at health centres as compared to hospitals. Segmented linear regressions showed that the introduction of GMIS in October 2007 made the increase in facility deliveries and deliveries with skilled attendants significantly jump by 18 and 10% respectively. Results from qualitative data also suggest that the introduction of GMIS together with other interventions that aimed to improve access to essential maternal health services led to considerable improvements in public health facilities and a steep increase in facility deliveries. Home deliveries attended by traditional birth attendants decreased concomitantly. We also outline several operational issues and limitations of GMIS. The available evidence strongly suggests that GMIS is an effective mechanism to complement other interventions to improve health system performance and boost facility deliveries as well as skilled birth attendance; thereby contributing to the reduction of maternal mortality. Our findings provide useful lessons for Cambodia to further improve GMIS and for other low-income countries to implement similar results-based financing mechanisms.

The validity of birth and pregnancy histories in rural Bangladesh.

PubMed

Espeut, Donna; Becker, Stan

2015-08-28

Maternity histories provide a means of estimating fertility and mortality from surveys. The present analysis compares two types of maternity histories-birth histories and pregnancy histories-in three respects: (1) completeness of live birth and infant death reporting; (2) accuracy of the time placement of live births and infant deaths; and (3) the degree to which reported versus actual total fertility measures differ. The analysis covers a 15-year time span and is based on two data sources from Matlab, Bangladesh: the 1994 Matlab Demographic and Health Survey and, as gold standard, the vital events data from Matlab's Demographic Surveillance System. Both histories are near perfect in live-birth completeness; however, pregnancy histories do better in the completeness and time accuracy of deaths during the first year of life. Birth or pregnancy histories can be used for fertility estimation, but pregnancy histories are advised for estimating infant mortality.

The Role of Distance and Quality on Facility Selection for Maternal and Child Health Services in Urban Kenya.

PubMed

Escamilla, Veronica; Calhoun, Lisa; Winston, Jennifer; Speizer, Ilene S

2018-02-01

Universal access to health care requires service availability and accessibility for those most in need of maternal and child health services. Women often bypass facilities closest to home due to poor quality. Few studies have directly linked individuals to facilities where they sought maternal and child health services and examined the role of distance and quality on this facility choice. Using endline data from a longitudinal survey from a sample of women in five cities in Kenya, we examine the role of distance and quality on facility selection for women using delivery, facility-based contraceptives, and child health services. A survey of public and private facilities offering reproductive health services was also conducted. Distances were measured between household cluster location and both the nearest facility and facility where women sought care. A quality index score representing facility infrastructure, staff, and supply characteristics was assigned to each facility. We use descriptive statistics to compare distance and quality between the nearest available facility and visited facility among women who bypassed the nearest facility. Facility distance and quality comparisons were also stratified by poverty status. Logistic regression models were used to measure associations between the quality and distance to the nearest facility and bypassing for each outcome. The majority of women bypassed the nearest facility regardless of service sought. Women bypassing for delivery traveled the furthest and had the fewest facility options near their residential cluster. Poor women bypassing for delivery traveled 4.5 km further than non-poor women. Among women who bypassed, two thirds seeking delivery and approximately 46% seeking facility-based contraception or child health services bypassed to a public hospital. Both poor and non-poor women bypassed to higher quality facilities. Our findings suggest that women in five cities in Kenya prefer public hospitals and are willing to travel further to obtain services at public hospitals, possibly related to free service availability. Over time, it will be important to examine service quality and availability in public sector facilities with reduced or eliminated user fees, and whether it lends itself to a continuum of care where women can visit one facility for multiple services reducing travel burden.

Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review

PubMed Central

Lazzerini, Marzia; Richardson, Sonia; Ciardelli, Valentina; Erenbourg, Anna

2018-01-01

Objectives The maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs). Methods Studies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care. Results Out of 24 822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95% CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported. Conclusions Policy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle particularly on outcomes reflecting patient-centred care and cost-effectiveness. PMID:29674368

Safer childbirth: a rights-based approach.

PubMed

Boama, Vincent; Arulkumaran, Sabaratnam

2009-08-01

The Millennium Development Goals (MDGs) set very high targets for women's reproductive health through reductions in maternal and infant mortality, among other things. Reductions in maternal mortality and morbidity can be achieved through various different approaches, such as the confidential review of maternal deaths, use of evidence-based treatments and interventions, using a health systems approach, use of information technology, global and regional partnerships, and making pregnancy safer through initiatives that increase the focus on human rights. A combination of these and other approaches can have a synergistic impact on reductions in maternal mortality. This paper highlights some of the current global efforts on safer pregnancy with a focus on reproductive rights. We encourage readers to do more in every corner of the world to advocate for women's reproductive rights and, in this way, we may achieve the MDGs by 2015.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

PubMed Central

Carroli, Guillermo; Zavaleta, Nelly; Donner, Allan; Wojdyla, Daniel; Faundes, Anibal; Velazco, Alejandro; Bataglia, Vicente; Langer, Ana; Narváez, Alberto; Valladares, Eliette; Shah, Archana; Campodónico, Liana; Romero, Mariana; Reynoso, Sofia; de Pádua, Karla Simônia; Giordano, Daniel; Kublickas, Marius; Acosta, Arnaldo

2007-01-01

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage). Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations. PMID:17977819

Supply-side barriers to maternity-care in India: a facility-based analysis.

PubMed

Kumar, Santosh; Dansereau, Emily

2014-01-01

Health facilities in many low- and middle-income countries face several types of barriers in delivering quality health services. Availability of resources at the facility may significantly affect the volume and quality of services provided. This study investigates the effect of supply-side determinants of maternity-care provision in India. Health facility data from the District-Level Household Survey collected in 2007-2008 were analyzed to explore the effects of supply-side factors on the volume of delivery care provided at Indian health facilities. A negative binomial regression model was applied to the data due to the count and over-dispersion property of the outcome variable (number of deliveries performed at the facility). Availability of a labor room (Incidence Rate Ratio [IRR]: 1.81; 95% Confidence Interval [CI]: 1.68-1.95) and facility opening hours (IRR: 1.43; CI: 1.35-1.51) were the most significant predictors of the volume of delivery care at the health facilities. Medical and paramedical staff were found to be positively associated with institutional deliveries. The volume of deliveries was also higher if adequate beds, essential obstetric drugs, medical equipment, electricity, and communication infrastructures were available at the facility. Findings were robust to the inclusion of facility's catchment area population and district-level education, health insurance coverage, religion, wealth, and fertility. Separate analyses were performed for facilities with and without a labor room and results were qualitatively similar across these two types of facilities. Our study highlights the importance of supply-side barriers to maternity-care India. To meet Millennium Development Goals 4 and 5, policymakers should make additional investments in improving the availability of medical drugs and equipment at primary health centers (PHCs) in India.

Supply-Side Barriers to Maternity-Care in India: A Facility-Based Analysis

PubMed Central

Kumar, Santosh; Dansereau, Emily

2014-01-01

Background Health facilities in many low- and middle-income countries face several types of barriers in delivering quality health services. Availability of resources at the facility may significantly affect the volume and quality of services provided. This study investigates the effect of supply-side determinants of maternity-care provision in India. Methods Health facility data from the District-Level Household Survey collected in 2007–2008 were analyzed to explore the effects of supply-side factors on the volume of delivery care provided at Indian health facilities. A negative binomial regression model was applied to the data due to the count and over-dispersion property of the outcome variable (number of deliveries performed at the facility). Results Availability of a labor room (Incidence Rate Ratio [IRR]: 1.81; 95% Confidence Interval [CI]: 1.68–1.95) and facility opening hours (IRR: 1.43; CI: 1.35–1.51) were the most significant predictors of the volume of delivery care at the health facilities. Medical and paramedical staff were found to be positively associated with institutional deliveries. The volume of deliveries was also higher if adequate beds, essential obstetric drugs, medical equipment, electricity, and communication infrastructures were available at the facility. Findings were robust to the inclusion of facility's catchment area population and district-level education, health insurance coverage, religion, wealth, and fertility. Separate analyses were performed for facilities with and without a labor room and results were qualitatively similar across these two types of facilities. Conclusions Our study highlights the importance of supply-side barriers to maternity-care India. To meet Millennium Development Goals 4 and 5, policymakers should make additional investments in improving the availability of medical drugs and equipment at primary health centers (PHCs) in India. PMID:25093729

Unpacking the enabling factors for hand, cord and birth-surface hygiene in Zanzibar maternity units

PubMed Central

Gon, Giorgia; Ali, Said M; Towriss, Catriona; Kahabuka, Catherine; Ali, Ali O; Cavill, Sue; Dahoma, Mohammed; Faulkner, Sally; Haji, Haji S; Kabole, Ibrahim; Morrison, Emma; Said, Rukaiya M; Tajo, Amour; Velleman, Yael; Woodd, Susannah L; Graham, and Wendy J

2017-01-01

Abstract Recent national surveys in The United Republic of Tanzania have revealed poor standards of hygiene at birth in facilities. As more women opt for institutional delivery, improving basic hygiene becomes an essential part of preventative strategies for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action. Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar. We used a mixed methods approach, including structured and semi-structured interviews, and environmental microbiology. Data were analysed according to the WHO ‘cleans’ framework, focusing on the fundamental practices for prevention of newborn and maternal sepsis. For each ‘clean’ we explored the following enabling factors: knowledge, infrastructure (including equipment), staffing levels and policies. Composite indices were constructed for the enabling factors of the ‘cleans’ from the quantitative data: clean hands, cord cutting, and birth surface. Results from the qualitative tools were used to complement this information. Only 49% of facilities had the ‘infrastructural’ requirements to enable ‘clean hands’, with the availability of constant running water particularly lacking. Less than half (46%) of facilities met the ‘knowledge’ requirements for ensuring a ‘clean delivery surface’; six out of seven facilities had birthing surfaces that tested positive for multiple potential pathogens. Almost two thirds of facilities met the ‘infrastructure (equipment) requirement’ for ‘clean cord’; however, disposable cord clamps being frequently out of stock, often resulted in the use of non-sterile thread made of fabric. This mixed methods approach, and the analytical framework based on the WHO ‘cleans’ and the enabling factors, yielded practical information of direct relevance to action at local and ministerial levels. The same approach could be applied to collect and analyse data on infection prevention from maternity units in other contexts. PMID:28931118

Out-of-pocket expenses for maternity care in rural Bangladesh: a public-private comparison.

PubMed

Rahman, Moshiur; Rob, Ubaidur; Noor, Forhana Rahman; Bellows, Benjamin

Out-of-pocket expenses incurred by women for availing maternal healthcare services at public and private health facilities in Bangladesh were examined using a baseline household survey evaluating the impact of demand side financing vouchers on utilization and service delivery for maternal healthcare. The survey was conducted in 2010 among 3,300 women who gave birth in the previous 12 months from the start of data collection. Information on costs incurred to receive antenatal, delivery, and postnatal care services was collected. Findings reveal that the majority of women reported paying out-of-pocket expenses for availing maternal healthcare services both at public and private health facilities. Out-of-pocket expenses include registration, consultation, laboratory examination, medicine, transportation, and other associated costs incurred for receiving maternal healthcare services. On average, women paid US$3.60 out-of-pocket expenses for receiving antenatal care at public health facilities and US$12.40 at private health facilities. Similarly, women paid one and half times more for normal (US$42.30) and cesarean deliveries (US$136.20) at private health facilities compared to public health facilities. On the other hand, costs for postnatal care services did not vary significantly between public and private health facilities. Utilization of maternal healthcare services can be improved if out-of-pocket expenses can be minimized. At the same time, effective demand generation strategies are necessary to encourage women to utilize health facilities.

Inefficiency, heterogeneity and spillover effects in maternal care in India: a spatial stochastic frontier analysis.

PubMed

Kinfu, Yohannes; Sawhney, Monika

2015-03-25

Institutional delivery is one of the key and proven strategies to reduce maternal deaths. Since the 1990s, the government of India has made substantial investment on maternal care to reduce the huge burden of maternal deaths in the country. However, despite the effort access to institutional delivery in India remains below the global average. In addition, even in places where health investments have been comparable, inter- and intra-state difference in access to maternal care services remain wide and substantial. This raises a fundamental question on whether the sub-national units themselves differ in terms of the efficiency with which they use available resources, and if so, why? Data obtained from round 3 of the country's District Level Health and Facility Survey was analyzed to measure the level and determinants of inefficiency of institutional delivery in the country. Analysis was conducted using spatial stochastic frontier models that correct for heterogeneity and spatial interactions between sub-national units. Inefficiency differences in maternal care services between and within states are substantial. The top one third of districts in the country has a mean efficiency score of 90 per cent or more, while the bottom 10 per cent of districts exhibit mean inefficiency score of as high as over 75 per cent or more. Overall mean inefficiency is about 30 per cent. The result also reveals the existence of both heterogeneity and spatial correlation in institutional delivery in the country. Given the high level of inefficiency in the system, further progress in improving coverage of institutional delivery in the country should focus both on improving the efficiency of resource utilization--especially where inefficiency levels are extremely high--and on bringing new resources in to the system. The additional investment should specifically focus on those parts of the country where coverage rates are still low but efficiency levels are already at a high level. In addition, given that inefficiency was also associated inversely with literacy and urbanization and positively related with proportion of households belonging to poor households, investment in these areas can also improve coverage of institutional delivery in the country.

The Effect of Maternal Death on the Health of the Husband and Children in a Rural Area of China: A Prospective Cohort Study.

PubMed

Zhou, Hong; Zhang, Long; Ye, Fang; Wang, Hai-Jun; Huntington, Dale; Huang, Yanjie; Wang, Anqi; Liu, Shuiqing; Wang, Yan

2016-01-01

To examine the effects of maternal death on the health of the index child, the health and educational attainment of the older children, and the mental health and quality of life of the surviving husband. A cohort study including 183 households that experienced a maternal death matched to 346 households that experienced childbirth but not a maternal death was conducted prospectively between June 2009 and October 2011 in rural China. Data on household sociodemographic characteristics, physical and mental health were collected using a quantitative questionnaire and medical examination at baseline and follow-up surveys. Multivariate linear regression, logistic regression models and difference-in-difference (DID) were used to compare differences of outcomes between two groups. The index children who experienced the loss of a mother had a significantly higher likelihood of dying, abandonment and malnutrition compared to children whose mothers survived at the follow-up survey. The risk of not attending school on time and dropping out of school among older children in the affected group was higher than those in the control group during the follow-up. Husbands whose wife died had significantly lower EQ-5D index and EQ-VAS both at baseline and at follow-up surveys compared to those without experiencing a wife's death, suggesting an immediate and sustained poorer mental health quality of life among the surviving husbands. Also the prevalence of posttraumatic stress disorder (PTSD) was 72.6% at baseline and 56.2% at follow-up among husbands whose wife died. Maternal death has multifaceted and spillover effects on the physical and mental health of family members that are sustained over time. Programmes that reduce maternal mortality will mitigate repercussions on surviving family members are critical and needed.

Sowing the seeds of transformative practice to actualize women's rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research.

PubMed

Warren, Charlotte E; Ndwiga, Charity; Sripad, Pooja; Medich, Melissa; Njeru, Anne; Maranga, Alice; Odhiambo, George; Abuya, Timothy

2017-08-30

Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima's successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

Improved Ascertainment of Pregnancy-Associated Suicides and Homicides in North Carolina.

PubMed

Austin, Anna E; Vladutiu, Catherine J; Jones-Vessey, Kathleen A; Norwood, Tammy S; Proescholdbell, Scott K; Menard, M Kathryn

2016-11-01

Injuries, including those resulting from violence, are a leading cause of death during pregnancy and the postpartum period. North Carolina, along with other states, has implemented surveillance systems to improve reporting of maternal deaths, but their ability to capture violent deaths is unknown. The purpose of this study was to quantify the improvement in ascertainment of pregnancy-associated suicides and homicides by linking data from the North Carolina Violent Death Reporting System (NC-VDRS) to traditional maternal mortality surveillance files. Enhanced case ascertainment was used to identify suicides and homicides that occurred during or up to 1 year after pregnancy from 2005 to 2011 in North Carolina. NC-VDRS data were linked to traditional maternal mortality surveillance files (i.e., death certificates with any mention of pregnancy or matched to a live birth or fetal death record and hospital discharge records for women who died in the hospital with a pregnancy-related diagnosis). Mortality ratios were calculated by case ascertainment method. Analyses were conducted in 2015. A total of 29 suicides and 55 homicides were identified among pregnant and postpartum women through enhanced case ascertainment as compared with 20 and 34, respectively, from traditional case ascertainment. Linkage to NC-VDRS captured 55.6% more pregnancy-associated violent deaths than traditional surveillance alone, resulting in higher mortality ratios for suicide (2.3 vs 3.3 deaths per 100,000 live births) and homicide (3.9 vs 6.2 deaths per 100,000 live births). Linking traditional maternal mortality files to NC-VDRS provided a notable improvement in ascertainment of pregnancy-associated violent deaths. Published by Elsevier Inc.

The operations of the free maternal care policy and out of pocket payments during childbirth in rural Northern Ghana.

PubMed

Dalinjong, Philip Ayizem; Wang, Alex Y; Homer, Caroline S E

2017-11-22

To promote skilled attendance at births and reduce maternal deaths, the government of Ghana introduced the free maternal care policy under the National Health Insurance Scheme (NHIS) in 2008. The objective is to eliminate financial barriers associated with the use of services. But studies elsewhere showed that out of pocket (OOP) payments still exist in the midst of fee exemptions. The aim of this study was to estimate OOP payments and the financial impact on women during childbirth in one rural and poor area of Northern Ghana; the Kassena-Nankana municipality. Costs were taken from the perspective of women. Quantitative and qualitative data collection techniques were used in a convergent parallel mixed methods study. The study used structured questionnaire (n = 353) and focus group discussions (FGDs =7) to collect data from women who gave birth in health facilities. Quantitative data from the questionnaire were analysed, using descriptive statistics. Qualitative data from the FGDs were recorded, transcribed and analysed to determine common themes. The overall mean OOP payments during childbirth was GH¢33.50 (US$17), constituting 5.6% of the average monthly household income. Over one-third (36%, n = 145) of women incurred OOP payments which exceeded 10% of average monthly household income (potentially catastrophic). Sixty-nine percent (n = 245) of the women perceived that the NHIS did not cover all expenses incurred during childbirth; which was confirmed in the FGDs. Both survey and FGDs demonstrated that women made OOP payments for drugs and other supplies. The FGDs showed women bought disinfectants, soaps, rubber pads and clothing for newborns as well. Seventy-five percent (n = 264) of the women used savings, but 19% had to sell assets to finance the payments; this was supported in the FGDs. The NHIS policy has not eliminated financial barriers associated with childbirth which impacts the welfare of some women. Women continued to make OOP payments, largely as a result of a delay in reimbursement by the NHIS. There is need to re-examine the reimbursement system in order to prevent shortage of funding to health facilities and thus encourage skilled attendance for the reduction of maternal deaths as well as the achievement of universal health coverage.

Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piaui, Brazil.

PubMed

Madeiro, Alberto Pereira; Rufino, Andréa Cronemberger; Lacerda, Érica Zânia Gonçalves; Brasil, Laís Gonçalves

2015-09-07

Maternal near miss (MNM) investigation is a useful tool for monitoring standards for obstetric care. This study evaluated the prevalence and the determinants of severe maternal morbidity (SMM) and MNM in a tertiary referral hospital in Teresina, Piauí, Brazil. A transversal and prospective study was conducted between September 2012 and February 2013. The cases were included according to criteria established by the WHO. Odds ratio, their respective confidence intervals, and multivariate analyses were examined. Five thousand eight hundred forty one live births, 343 women with SMM, 56 cases of MNM, and 10 maternal deaths were investigated. The rate for severe maternal outcomes was 11.2 cases per 1000 live births, the rate of MNM was 9.6 cases/1000 live births, and the rate for mortality was 171.2 cases/100,000 live births. Management criteria were most frequently observed among MNM/death cases. Hypertensive diseases (86.1%) and hemorrhagic complications (10.0%) were the main determinants of MNM, but infectious abortion was the most common isolated cause of maternal death. There was a correlation between MNM/death and hospitalized more than 5 days (p = 0.023) and between termination of pregnancy by cesarean (p = 0.002) and APGAR < 7 in the 1(st) minute (p = 0.015). SMM and MNM were quite prevalent in the population studied. Women whose condition progressed to MNM/death had a higher association with terminating pregnancy by cesarean, longer hospitalization times, and worse perinatal results. The results from the study can be useful to improve the quality of obstetric care and consequently diminish maternal mortality in the region.

Effect of Early Detection and Treatment on Malaria Related Maternal Mortality on the North-Western Border of Thailand 1986–2010

PubMed Central

McGready, Rose; Boel, Machteld; Rijken, Marcus J.; Ashley, Elizabeth A.; Cho, Thein; Moo, Oh; Paw, Moo Koh; Pimanpanarak, Mupawjay; Hkirijareon, Lily; Carrara, Verena I.; Lwin, Khin Maung; Phyo, Aung Pyae; Turner, Claudia; Chu, Cindy S.; van Vugt, Michele; Price, Richard N.; Luxemburger, Christine; ter Kuile, Feiko O.; Tan, Saw Oo; Proux, Stephane; Singhasivanon, Pratap; White, Nicholas J.; Nosten, François H.

2012-01-01

Introduction Maternal mortality is high in developing countries, but there are few data in high-risk groups such as migrants and refugees in malaria-endemic areas. Trends in maternal mortality were followed over 25 years in antenatal clinics prospectively established in an area with low seasonal transmission on the north-western border of Thailand. Methods and Findings All medical records from women who attended the Shoklo Malaria Research Unit antenatal clinics from 12th May 1986 to 31st December 2010 were reviewed, and maternal death records were analyzed for causality. There were 71 pregnancy-related deaths recorded amongst 50,981 women who attended antenatal care at least once. Three were suicide and excluded from the analysis as incidental deaths. The estimated maternal mortality ratio (MMR) overall was 184 (95%CI 150–230) per 100,000 live births. In camps for displaced persons there has been a six-fold decline in the MMR from 499 (95%CI 200–780) in 1986–90 to 79 (40–170) in 2006–10, p<0.05. In migrants from adjacent Myanmar the decline in MMR was less significant: 588 (100–3260) to 252 (150–430) from 1996–2000 to 2006–2010. Mortality from P.falciparum malaria in pregnancy dropped sharply with the introduction of systematic screening and treatment and continued to decline with the reduction in the incidence of malaria in the communities. P.vivax was not a cause of maternal death in this population. Infection (non-puerperal sepsis and P.falciparum malaria) accounted for 39.7 (27/68) % of all deaths. Conclusions Frequent antenatal clinic screening allows early detection and treatment of falciparum malaria and substantially reduces maternal mortality from P.falciparum malaria. No significant decline has been observed in deaths from sepsis or other causes in refugee and migrant women on the Thai–Myanmar border. PMID:22815732

Analysis of inequality in maternal and child health outcomes and mortality from 2000 to 2013 in China.

PubMed

Li, Yanting; Zhang, Yimin; Fang, Shuai; Liu, Shanshan; Liu, Xinyu; Li, Ming; Liang, Hong; Fu, Hua

2017-04-20

Inequality in maternal and child health seriously hinders the overall improvement of health, which is a concern in both the United Nations Sustainable Development Goals (SDGs) and Healthy China 2030. However, research on the equality of maternal and child health is scarce. This study longitudinally assessed the equality trends in China's maternal and child health outcomes from 2000 to 2013 based on place of residence and gender to improve the fairness of domestic maternal and child health. Data on China's maternal and child health monitoring reports were collected from 2000 to 2013. Horizontal and vertical monitoring were performed on the following maternal and child health outcome indicators: incidence of birth defects (IBD), maternal mortality rate (MMR), under 5 mortality rate (U5MR) and neonatal mortality rate (NMR). The newly developed HD*Calc software by the World Health Organization (WHO) was employed as a tool for the health inequality assessment. The between group variance (BGV) and the Theil index (T) were used to measure disparity between different population groups, and the Slope index was used to analyse the BGV and T trends. The disparity in the MMR, U5MR and NMR for the different places of residence (urban and rural) improved over time. The BGV (Slope BGV = -32.24) and T (Slope T = -7.87) of MMR declined the fastest. The gender differences in the U5MR (Slope BGV = -0.06, Slope T = -0.21) and the NMR (Slope BGV = -0.01, Slope T = 0.23) were relatively stable, but the IBD disparity still showed an upward trend in both the place of residence and gender strata. A decline in urban-rural differences in the cause of maternal death was found for obstetric bleeding (Slope BGV = -14.61, Slope T = -20.84). Improvements were seen in the urban-rural disparity in premature birth and being underweight (PBU) in children under 5 years of age. Although diarrhoea and pneumonia decreased in the U5MR, no obvious gender-based trend in the causes of death was observed. We found improvement in the disparity of maternal and child health outcomes in China. However, the improvements still do not meet the requirements proposed by the Healthy China 2030 strategy, particularly regarding the rise in the IBD levels and the decline in equality. This study suggests starting with maternal and child health services and focusing on the disparity in the causes of death in both the place of residence and gender strata. Placing an emphasis on health services may encourage the recovery of the premarital check and measures such as prenatal and postnatal examinations to improve equality.

Improving the maternal mortality ratio in Zhejiang Province, China, 1988-2008.

PubMed

Qiu, Liqian; Lin, Jun; Ma, Yuanying; Wu, Weiwei; Qiu, Ling; Zhou, Aizhen; Shi, Wenjun; Lee, Andy; Binns, Colin

2010-10-01

maternal mortality remains a major public health problem in many countries. The aim of this paper is to describe the progress made in maternal health care in Zhejiang Province, China over 20 years in reducing the maternal mortality ratio (MMR). Zhejiang Province is located on the mid-east coast of China, approximately 180km south of Shanghai, and has a population of 49 million. Almost all mothers give birth in hospitals or maternal and infant health institutes. the annual maternal death audit reports from 1988 to 2008 were analysed. These reports were prepared annually by the Zhejiang Prenatal Health Committee after auditing each individual case. China has made considerable progress in reducing the MMR. Zhejiang has one of fastest developing economies in China, and since the 86 economic reforms of 1978, health care has improved rapidly and the MMR has declined. During the 1988-2008 period, 2258 maternal deaths were reported from 8,880,457 live births. During these two decades, the MMR decreased dramatically from 48.50 in 1988 to 6.57 per 100,000 in 2008. The MMR in migrant women dropped from 66.87 in 2003 to 21.67 per 100,000 in 2008. The rate of decline was more rapid in rural areas than in the city. There has been a decline in the proportion of deaths with direct obstetric causes and a corresponding increase in the proportion of indirect causes. The proportion of deaths classified as preventable has declined in the past two decades. Social factors are important in maternal safety, and on average 26.8% of maternal deaths were influenced by these factors. as the economy was developing, maternal safety was made a priority health issue by the Government and health workers. The provincial MMR has dropped rapidly and is now similar to the rates in developed countries and lower than that in the USA. However, more work is still needed to ensure that all mothers, including migrant workers, continue to have these low rates. Copyright © 2010 Elsevier Ltd. All rights reserved.

Causes of adult female deaths in Bangladesh: findings from two National Surveys.

PubMed

Nahar, Quamrun; El Arifeen, Shams; Jamil, Kanta; Streatfield, Peter Kim

2015-09-18

Assessment of causes of death and changes in pattern of causes of death over time are needed for programmatic purposes. Limited national level data exist on the adult female causes of death in Bangladesh. Using data from two nationally representation surveys, the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS), the paper examines the causes of adult female death, aged 15-49 years, and changes in the patterns of these deaths. In both surveys, all household deaths three years prior to the survey were identified. Adult female deaths were then followed by a verbal autopsy (VA) using the WHO structured questionnaire. Two physicians independently reviewed the VA forms to assign a cause of death using the ICD-10; in case of disagreement, a third physician made an independent review and assigned a cause of death. The overall mortality rates for women aged 15-49 in 2001 and 2010 were 182 per 100,000 and 120 per 100,000 respectively. There is a shift in the pattern of causes of death during the period covered by the two surveys. In the 2001 survey, the main causes of death were maternal (20 %), followed by diseases of the circulatory system (15 %), malignancy (14 %) and infectious diseases (13 %). However, in the 2010 survey, malignancies were the leading cause (21 %), followed by diseases of the circulatory system (16 %), maternal causes (14 %) and infectious diseases (8 %). While maternal deaths remained the number one cause of death among 20-34 years old in both surveys, unnatural deaths were the main cause for teenage deaths, and malignancies were the main cause of death for older women. Although there is an increasing trend in the proportion of women who died in hospitals, in both surveys most women died at home (74 % in 2001 and 62 % in 2010). The shift in the pattern of causes of adult female deaths is in agreement with the overall change in the disease pattern from communicable to non-communicable diseases in Bangladesh. Suicide and other violent deaths as the primary cause of deaths among teenage girls demands specific interventions to prevent such premature deaths. Prevention of deaths due to non-communicable diseases should also be a priority.

Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect

PubMed Central

2011-01-01

Background Of 136 million babies born annually, around 10 million require assistance to breathe. Each year 814,000 neonatal deaths result from intrapartum-related events in term babies (previously “birth asphyxia”) and 1.03 million from complications of prematurity. No systematic assessment of mortality reduction from tactile stimulation or resuscitation has been published. Objective To estimate the mortality effect of immediate newborn assessment and stimulation, and basic resuscitation on neonatal deaths due to term intrapartum-related events or preterm birth, for facility and home births. Methods We conducted systematic reviews for studies reporting relevant mortality or morbidity outcomes. Evidence was assessed using GRADE criteria adapted to provide a systematic approach to mortality effect estimates for the Lives Saved Tool (LiST). Meta-analysis was performed if appropriate. For interventions with low quality evidence but strong recommendation for implementation, a Delphi panel was convened to estimate effect size. Results We identified 24 studies of neonatal resuscitation reporting mortality outcomes (20 observational, 2 quasi-experimental, 2 cluster randomized controlled trials), but none of immediate newborn assessment and stimulation alone. A meta-analysis of three facility-based studies examined the effect of resuscitation training on intrapartum-related neonatal deaths (RR= 0.70, 95%CI 0.59-0.84); this estimate was used for the effect of facility-based basic neonatal resuscitation (additional to stimulation). The evidence for preterm mortality effect was low quality and thus expert opinion was sought. In community-based studies, resuscitation training was part of packages with multiple concurrent interventions, and/or studies did not distinguish term intrapartum-related from preterm deaths, hence no meta-analysis was conducted. Our Delphi panel of 18 experts estimated that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10%, facility-based resuscitation would prevent a further 10% of preterm deaths, and community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths. Conclusion Neonatal resuscitation training in facilities reduces term intrapartum-related deaths by 30%. Yet, coverage of this intervention remains low in countries where most neonatal deaths occur and is a missed opportunity to save lives. Expert opinion supports smaller effects of neonatal resuscitation on preterm mortality in facilities and of basic resuscitation and newborn assessment and stimulation at community level. Further evaluation is required for impact, cost and implementation strategies in various contexts. Funding This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to the Saving Newborn Lives program of Save the Children, through Save the Children US. PMID:21501429

[Effect of maternal death on family dynamics and infant survival].

PubMed

Reyes Frausto, S; Bobadilla Fernández, J L; Karchmer Krivitzky, S; Martínez González, L

1998-10-01

Family adjustments, which are generated by a maternal death, have been analysed previously in Mexico by using a reduced number of cases in rural areas. This study was design in order to establish changes in family dynamic generated b y a maternal death and to analyse child surviving after one year of birth. Family members of maternal deaths cases, which occurred during 1988-89 in the Federal District, were interviewed by first time in order to know information related to family dynamic and women's characteristics. A second interview was made after one year of birth for cases in which the newborn survived hospital discharge. Simple frequencies were calculated and using X2 test compared groups. Main consequences were family disintegration, child acquiring new roles and economic problems when woman was the main or the only one support of the family. Child surviving was higher than we expected considering other national or international reports. Children were mainly integrated to their grandparent's family.

A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned

PubMed Central

Orobaton, Nosakhare; Abegunde, Dele; Shoretire, Kamil; Abdulazeez, Jumare; Fapohunda, Bolaji; Lamiri, Goli; Maishanu, Abubakar; Ganiyu, Akeem; Ndifon, Eric; Gwamzhi, Ringpon; Osborne-Smith, Matthew

2015-01-01

Background With an annual estimated 276,000 neonatal deaths, Nigeria has the second highest of any country in the world. Global progress in accelerating neonatal deaths is hinged to scaled-up interventions in Nigeria. We used routine data of chlorhexidine digluconate 7.1% gel utilized by 36,404 newborns delivered by 36,370 mothers, to study lessons associated with at-scale distribution in Sokoto State, North West Nigeria. Methods and Findings Under state government leadership, a community-based distribution system overseen by 244 ward development committees and over 3,440 community-based health volunteers and community drug keepers, was activated to deliver two locally stored medicines to women when labor commenced. Newborns and their mothers were tracked through 28 days and 42 days respectively, including verbal autopsy results. 36,404 or 26.3% of expected newborns received the gel from April 2013 to December 2013 throughout all 244 wards in the State. 99.97% of newborns survived past 28 days. There were 124 pre-verified neonatal deaths reported. Upon verification using verbal autopsy procedures, 76 deaths were stillborn and 48 were previously live births. Among the previous 48 live births, the main causes of death were sepsis (40%), asphyxia (29%) and prematurity (8%). Underuse of logistics management information by government in procurement decisions and not accounting for differences in LGA population sizes during commodity distribution, severely limited program scalability. Conclusions Enhancements in the predictable availability and supply of chlorhexidine digluconate 7.1% gel to communities through better, evidence-based logistics management by the state public sector will most likely dramatically increase program scalability. Infections as a cause of mortality in babies delivered in home settings may be much higher than previously conceived. In tandem with high prevalence of stillborn deaths, delivery, interventions designed to increase mothers’ timely and regular use of quality antenatal care, and increased facility-based based delivery, need urgent attention. We call for accelerated investments in community health volunteer programs and the requisite community measurement systems to better track coverage. We also advocate for the development, refinement and use of routine community-based verbal autopsies to track newborn and maternal survival. PMID:26226017

A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned.

PubMed

Orobaton, Nosakhare; Abegunde, Dele; Shoretire, Kamil; Abdulazeez, Jumare; Fapohunda, Bolaji; Lamiri, Goli; Maishanu, Abubakar; Ganiyu, Akeem; Ndifon, Eric; Gwamzhi, Ringpon; Osborne-Smith, Matthew

2015-01-01

With an annual estimated 276,000 neonatal deaths, Nigeria has the second highest of any country in the world. Global progress in accelerating neonatal deaths is hinged to scaled-up interventions in Nigeria. We used routine data of chlorhexidine digluconate 7.1% gel utilized by 36,404 newborns delivered by 36,370 mothers, to study lessons associated with at-scale distribution in Sokoto State, North West Nigeria. Under state government leadership, a community-based distribution system overseen by 244 ward development committees and over 3,440 community-based health volunteers and community drug keepers, was activated to deliver two locally stored medicines to women when labor commenced. Newborns and their mothers were tracked through 28 days and 42 days respectively, including verbal autopsy results. 36,404 or 26.3% of expected newborns received the gel from April 2013 to December 2013 throughout all 244 wards in the State. 99.97% of newborns survived past 28 days. There were 124 pre-verified neonatal deaths reported. Upon verification using verbal autopsy procedures, 76 deaths were stillborn and 48 were previously live births. Among the previous 48 live births, the main causes of death were sepsis (40%), asphyxia (29%) and prematurity (8%). Underuse of logistics management information by government in procurement decisions and not accounting for differences in LGA population sizes during commodity distribution, severely limited program scalability. Enhancements in the predictable availability and supply of chlorhexidine digluconate 7.1% gel to communities through better, evidence-based logistics management by the state public sector will most likely dramatically increase program scalability. Infections as a cause of mortality in babies delivered in home settings may be much higher than previously conceived. In tandem with high prevalence of stillborn deaths, delivery, interventions designed to increase mothers' timely and regular use of quality antenatal care, and increased facility-based based delivery, need urgent attention. We call for accelerated investments in community health volunteer programs and the requisite community measurement systems to better track coverage. We also advocate for the development, refinement and use of routine community-based verbal autopsies to track newborn and maternal survival.

Saving maternal lives in resource-poor settings: facing reality.

PubMed

Prata, Ndola; Sreenivas, Amita; Vahidnia, Farnaz; Potts, Malcolm

2009-02-01

Evaluate safe-motherhood interventions suitable for resource-poor settings that can be implemented with current resources. Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions. Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted. Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of these women deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.

Relating the construction and maintenance of maternal ill-health in rural Indonesia

PubMed Central

D'Ambruoso, Lucia

2012-01-01

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly. PMID:22872791

Relating the construction and maintenance of maternal ill-health in rural Indonesia.

PubMed

D'Ambruoso, Lucia

2012-01-01

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

[Toward safe motherhood: a call for action].

PubMed

Mahler, H

1987-12-01

The most shocking fact about maternal health today is the difference between maternal mortality rates in developed and developing countries. In developed countries, mortality risks range from 1/4000 to 1/10,000, but in developing countries the risk may be 1/15 to 1/50. Most countries with high maternal mortality rates have inadequate vital registration systems. The magnitude of the maternal mortality problem was unknown until recently, when reliable statistics from Asia, Africa, and Latin America became available. Discrimination against females in education, nutrition, and other aspects of life is a more or less direct cause of maternal mortality. Maternal deaths often have their roots in the life of the woman before the pregnancy or even before the woman's birth. Persistent deficiencies of calcium, vitamin D, or iron may result in a constricted pelvis, eventually leading to death during labor. Chronic anemia may lead to death from hemorrhage. Risks resulting from adolescent pregnancy, maternal exhaustion due to closely spaced births and heavy physical labor during the reproductive years, procreation after age 35 and especially after age 40, and illegal induced abortion are all factors in high maternal mortality rates in developing countries. The only hope of providing access to essential maternal health services, family planning, and especially obstetrical services for life threatening emergencies to poor women living in remote areas is through primary health care. Local health care cannot exist in a vacuum; technical and administrative help is required from municipal centers. Fewer than 50% of the world's women receive trained care during deliveries. The consequences of unregulated fertility are particularly important as a determinant of maternal mortality. The World Health Organization family planning policy is based on recognition of family planning as an inseparable part of maternal and child health care. Longterm economic and social development and elimination of female illiteracy are other parts of the multiple strategy of controlling maternal mortality. 4 steps are essential in strategies to control maternal mortality: 1) providing adequate health and nutrition services for girls and family planning services for women 2) providing good prenatal nutrition and health care and identifying high risk women early in the pregnancy 3) assuring professional attention for all deliveries, and 4) providing access to obstetrical care for high risk deliveries and obstetrical emergencies. Some of the needed resources to make childbearing safer already exist in each country and can be strengthened by cooperative efforts between national and local governments, international assistance agencies, nongovernmental organizations, and families and communities of each region.

Maternal mortality following caesarean sections.

PubMed

Sikdar, K; Kundu, S; Mandal, G S

1979-08-01

A study of 26 maternal deaths following 3647 caesarean sections was conducted in Eden Hospital from 1974-1977. During the time period there were 35,544 births and 308 total maternal deaths (8.74/1000). Indications for Caesarean sections included: 1) abnormal presentation; 2) cephalopelvic disproportion; 3) toxemia; 4) prolonged labor; 5) fetal distress; and 6) post-caesarean pregnancies. Highest mortality rates were among cephalopelvic disproportion, toxemia, and prolonged labor patients. 38.4% of the patients died due to septicaemia and peritonitis, but other deaths were due to preclampsia, shock, and hemorrhage. Proper antenatal care may have prevented anemia and preclampsia and treated other pre-existing or superimposed diseases.

User fees and maternity services in Ethiopia.

PubMed

Pearson, Luwei; Gandhi, Meena; Admasu, Keseteberhan; Keyes, Emily B

2011-12-01

To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia. The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008. Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively. Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Maternal mortality in the Islamic countries of the Eastern Mediterranean Region of WHO.

PubMed

El-haffez, G

1990-07-01

Maternal mortality in Islamic countries is high. Some reasons for high maternal mortality here include low average age of marriage, illiteracy, lack of prenatal care, and obstetric complications. In at least 3 Islamic countries it stands 50/10,000, but ranges from 20-49 in most Islamic countries. These figures are based on only a few studies in hospitals, however. In fact, 70-90% of deliveries do not take place in hospitals, particularly in rural areas. Moreover, traditional birth attendants (TBAs) deliver most infants. In addition, poor health information systems exist. WHO's Regional Office of the Eastern Mediterranean promotes maternal health projects designed to reduce maternal mortality. Specifically, it supports scientific inquiries into maternal deaths which can include talking to husbands about wives' deaths or having TBAs record infant and maternal events. WHO promotes self care by having mothers complete record cards. These cards are used in Yemen, Egypt, Pakistan, Syria, and Somalia. It also encourages maternal and child health/family planning (MCH/FP) programs to adopt a risk approach to expedite early referral care of high risk pregnant females. In fact, WHO sponsors workshops on risk approach in MCH/FP for physicians. It also fosters improvement of managerial and technical skills. WHO collaborates with medical, nursing, and paramedical schools in curriculum development for training students in MCH/FP. Similarly, it provides training for practicing obstetricians. Further, it promotes training of TBAs. WHO encourages each country to monitor and evaluate MCH/FP activities, to conduct health system research, and address unmet needs in maternal care. In conclusion, education is needed to dispel harmful traditional practices and countries should increase the role of the media to inform the public.

Engendering the Attainment of the SDG-3 in Africa: Overcoming the Socio Cultural Factors Contributing to Maternal Mortality.

PubMed

Ogu, Rosemary N; Agholor, Kingsley N; Okonofua, Friday E

2016-09-01

At the conclusion of the Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs) provide an opportunity to ensure healthy lives, promote the social well-being of women and end preventable maternal death. However, inequities in health and avoidable health inequalities occasioned by adverse social, cultural and economic influences and policies are major determinants as to whether a woman can access evidence-based clinical and preventative interventions for reducing maternal mortality. This review discusses sociocultural influences that contribute to the high rate of maternal mortality in Nigeria, a country categorised as having made -no progress‖ towards achieving MDG 5. We highlight the need for key interventions to mitigate the impact of negative sociocultural practices and social inequality that decrease women's access to evidence-based reproductive health services that lead to high rate of maternal mortality. Strategies to overcome identified negative sociocultural influences and ultimately galvanize efforts towards achieving one of the tenets of SDG-3 are recommended.

Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long–term mortality impact

PubMed Central

Perry, Henry B; Rassekh, Bahie M; Gupta, Sundeep; Freeman, Paul A

2017-01-01

Background There is limited evidence about the long–term effectiveness of integrated community–based primary health care (CBPHC) in improving maternal, neonatal and child health. However, the interventions implemented and the approaches used by projects with such evidence can provide guidance for ending preventable child and maternal deaths by the year 2030. Methods A database of 700 assessments of the effectiveness of CBPHC in improving maternal, neonatal and child health has been assembled, as described elsewhere in this series. A search was undertaken of these assessments of research studies, field project and programs (hereafter referred to as projects) with more than a single intervention that had evidence of mortality impact for a period of at least 10 years. Four projects qualified for this analysis: the Matlab Maternal Child Health and Family Planning (MCH–FP) P in Bangladesh; the Hôpital Albert Schweitzer in Deschapelles, Haiti; the Comprehensive Rural Health Project (CRHP) in Jamkhed, India; and the Society for Education, Action and Research in Community Health (SEARCH) in Gadchiroli, India. Results These four projects have all been operating for more than 30 years, and they all have demonstrated reductions in infant mortality, 1– to 4–year mortality, or under–5 mortality for at least 10 years. They share a number of characteristics. Among the most notable of these are: they provide comprehensive maternal, child health and family planning services, they have strong community–based programs that utilize community health workers who maintain regular contact with all households, they have develop strong collaborations with the communities they serve, and they all have strong referral capabilities and provide first–level hospital care. Conclusions The shared features of these projects provide guidance for how health systems around the world might improve their effectiveness in improving maternal, neonatal and child health. Strengthening these features will contribute to achieving the goal of ending preventable child and maternal deaths by the year 2030. PMID:28685045

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact.

PubMed

Perry, Henry B; Rassekh, Bahie M; Gupta, Sundeep; Freeman, Paul A

2017-06-01

There is limited evidence about the long-term effectiveness of integrated community-based primary health care (CBPHC) in improving maternal, neonatal and child health. However, the interventions implemented and the approaches used by projects with such evidence can provide guidance for ending preventable child and maternal deaths by the year 2030. A database of 700 assessments of the effectiveness of CBPHC in improving maternal, neonatal and child health has been assembled, as described elsewhere in this series. A search was undertaken of these assessments of research studies, field project and programs (hereafter referred to as projects) with more than a single intervention that had evidence of mortality impact for a period of at least 10 years. Four projects qualified for this analysis: the Matlab Maternal Child Health and Family Planning (MCH-FP) P in Bangladesh; the Hôpital Albert Schweitzer in Deschapelles, Haiti; the Comprehensive Rural Health Project (CRHP) in Jamkhed, India; and the Society for Education, Action and Research in Community Health (SEARCH) in Gadchiroli, India. These four projects have all been operating for more than 30 years, and they all have demonstrated reductions in infant mortality, 1- to 4-year mortality, or under-5 mortality for at least 10 years. They share a number of characteristics. Among the most notable of these are: they provide comprehensive maternal, child health and family planning services, they have strong community-based programs that utilize community health workers who maintain regular contact with all households, they have develop strong collaborations with the communities they serve, and they all have strong referral capabilities and provide first-level hospital care. The shared features of these projects provide guidance for how health systems around the world might improve their effectiveness in improving maternal, neonatal and child health. Strengthening these features will contribute to achieving the goal of ending preventable child and maternal deaths by the year 2030.

The role of a decision-support smartphone application in enhancing community health volunteers’ effectiveness to improve maternal and newborn outcomes in Nairobi, Kenya: quasi-experimental research protocol

PubMed Central

Bakibinga, Pauline; Kamande, Eva; Omuya, Milka; Ziraba, Abdhalah K; Kyobutungi, Catherine

2017-01-01

Introduction Improving maternal and newborn survival remains major aspirations for many countries in the Global South. Slum settlements, a result of rapid urbanisation in many developing countries including Kenya, exhibit high levels of maternal and neonatal mortality. There are limited referral mechanisms for sick neonates and their mothers from the community to healthcare facilities with ability to provide adequate care. In this study, we specifically plan to develop and assess the added value of having community health volunteers (CHVs) use smartphones to identify and track mothers and children in a bid to reduce pregnancy-related complications and newborn deaths in the urban slums of Kamukunji subcounty in Nairobi, Kenya. Methods and analysis This is a quasi-experimental study. We are implementing an innovative, mHealth application known as mobile Partnership for Maternal, Newborn and Child Health (mPAMANECH) which uses dynamic mobile phone and web-portal solutions to enable CHVs make timely decisions on the best course of action in their management of mothers and newborns at community level. The application is based on existing guidelines and protocols in use by CHVs. Currently, CHVs conduct weekly home visits and make decisions from memory or using unwieldy manual tools, and thus prone to making errors. mPAMANECH has an in-built algorithm that makes it easier, faster and more likely for CHVs to make the right management decision. We are working with a network of selected CHVs and maternity centres to pilot test the tool. To measure the impact of the intervention, baseline and end-line surveys will be conducted. Data will be obtained through qualitative and quantitative methods. Ethics and dissemination Ethical approval for the study was obtained from the African Medical Research Foundation. Key messages from the results will be packaged and disseminated through meetings, conference presentations, reports, fact sheets and academic publications to facilitate uptake by policy-makers. PMID:28729309

In-utero exposure to bereavement and offspring IQ: a Danish national cohort study.

PubMed

Virk, Jasveer; Obel, Carsten; Li, Jiong; Olsen, Jørn

2014-01-01

Intelligence is a life-long trait that has strong influences on lifestyle, adult morbidity and life expectancy. Hence, lower cognitive abilities are therefore of public health interest. Our primary aim was to examine if prenatal bereavement measured as exposure to death of a close family member is associated with the intelligence quotient (IQ) scores at 18-years of age of adult Danish males completing a military cognitive screening examination. We extracted records for the Danish military screening test and found kinship links with biological parents, siblings, and maternal grandparents using the Danish Civil Registration System (N = 167,900). The prenatal exposure period was defined as 12 months before conception until birth of the child. We categorized children as exposed in utero to severe stress (bereavement) during prenatal life if their mothers lost an elder child, husband, parent or sibling during the prenatal period; the remaining children were included in the unexposed cohort. Mean score estimates were adjusted for maternal and paternal age at birth, residence, income, maternal education, gestational age at birth and birth weight. When exposure was due to death of a father the offsprings' mean IQ scores were lower among men completing the military recruitment exam compared to their unexposed counterparts, adjusted difference of 6.5 standard IQ points (p-value = 0.01). We did not observe a clinically significant association between exposure to prenatal maternal bereavement caused by death of a sibling, maternal uncle/aunt or maternal grandparent even after stratifying deaths only due to traumatic events. We found maternal bereavement to be adversely associated with IQ in male offspring, which could be related to prenatal stress exposure though more likely is due to changes in family conditions after death of the father. This finding supports other literature on maternal adversity during fetal life and cognitive development in the offspring.

Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur, Bangladesh.

PubMed

Huda, Fauzia Akhter; Ahmed, Anisuddin; Dasgupta, Sushil Kanta; Jahan, Musharrat; Ferdous, Jannatul; Koblinsky, Marge; Ronsmans, Carine; Chowdhury, Mahbub Elahi

2012-06-01

Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases--either spontaneous or induced--were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospital-register. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh.

Profile of Maternal and Foetal Complications during Labour and Delivery among Women Giving Birth in Hospitals in Matlab and Chandpur, Bangladesh

PubMed Central

Ahmed, Anisuddin; Dasgupta, Sushil Kanta; Jahan, Musharrat; Ferdous, Jannatul; Koblinsky, Marge; Ronsmans, Carine; Chowdhury, Mahbub Elahi

2012-01-01

Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases—either spontaneous or induced—were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospital-register. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh. PMID:22838156

Association of Maternal Obesity with Child Cerebral Palsy or Death.

PubMed

McPherson, Jessica A; Smid, Marcela C; Smiley, Sarah; Stamilio, David M

2017-05-01

Objective  The primary aim of this study was to determine if there is an association between maternal obesity and cerebral palsy or death in children. Study Design  This is a retrospective cohort analysis of a randomized controlled clinical trial previously performed by the Maternal-Fetal Medicine Units Network. Women in the original trial were included if at high risk for preterm delivery. The present study included singletons enrolled in the original study with complete data. Obese and nonobese women were compared. A secondary analysis comparing class 3 obese or classes 1 to 2 obese women to nonobese women was performed. The primary outcome was a composite of cerebral palsy or perinatal death. Results  In this study, 1,261 nonobese, 339 obese, and 69 morbidly obese women were included. When adjusted for gestational age at delivery and magnesium exposure, there was no association between maternal obesity and child cerebral palsy or death. In the analysis using obesity severity categories, excess risk for adverse outcome appeared confined to the class 3 obese group. Conclusion  In women at high risk of delivering preterm, maternal obesity was not independently associated with child cerebral palsy or death. The association in unadjusted analysis appears to be mediated by preterm birth among obese patients. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi

PubMed Central

Manthalu, Gerald; Yi, Deokhee; Farrar, Shelley; Nkhoma, Dominic

2016-01-01

The Government of Malawi has signed contracts called service level agreements (SLAs) with mission health facilities in order to exempt their catchment populations from paying user fees. Government in turn reimburses the facilities for the services that they provide. SLAs started in 2006 with 28 out of 165 mission health facilities and increased to 74 in 2015. Most SLAs cover only maternal, neonatal and in some cases child health services due to limited resources. This study evaluated the effect of user fee exemption on the utilization of maternal health services. The difference-in-differences approach was combined with propensity score matching to evaluate the causal effect of user fee exemption. The gradual uptake of the policy provided a natural experiment with treated and control health facilities. A second control group, patients seeking non-maternal health care at CHAM health facilities with SLAs, was used to check the robustness of the results obtained using the primary control group. Health facility level panel data for 142 mission health facilities from 2003 to 2010 were used. User fee exemption led to a 15% (P <  0.01) increase in the mean proportion of women who made at least one antenatal care (ANC) visit during pregnancy, a 12% (P < 0.05) increase in average ANC visits and an 11% (P < 0.05) increase in the mean proportion of pregnant women who delivered at the facilities. No effects were found for the proportion of pregnant women who made the first ANC visit in the first trimester and the proportion of women who made postpartum care visits. We conclude that user fee exemption is an important policy for increasing maternal health care utilization. For certain maternal services, however, other determinants may be more important. PMID:27175033

Effectiveness of an NGO primary health care programme in rural Bangladesh: evidence from the management information system.

PubMed

Mercer, Alec; Khan, Mobarak Hossain; Daulatuzzaman, Muhammad; Reid, Joanna

2004-07-01

This paper considers evidence of the effectiveness of a non-governmental organization (NGO) primary health care programme in rural Bangladesh. It is based on data from the programme's management information system reported by 27 partner NGOs from 1996-2002. The data indicate relatively high coverage has been achieved for reproductive and child health services, as well as lower infant and child mortality. On the basis of a crude indicator of socio-economic status, the programme is poverty-focused. There is good service coverage among the poorest one-third and others, and the infant and child mortality differential has been eliminated over recent years. A rapid decline in infant mortality among the poorest from 1999-2002 reflects a reduction in neonatal mortality of about 50%. Allowing for some under-reporting and possible misclassification of deaths to the stillbirths category, neonatal mortality is relatively low in the NGO areas. The lower child and maternal mortality for the NGO areas combined, compared with estimates for Bangladesh in recent years, may at least in part be due to high coverage of reproductive and child health services. Other development programmes implemented by many of the NGOs could also have contributed. Despite the limited resources available, and the lower infant and child mortality already achieved, there appears to be scope for further prevention of deaths, particularly those due to birth asphyxia, acute respiratory infection, diarrhoeal disease and accidents. Maternal mortality in the NGO areas was lower in 2000-02 than the most recent estimate for Bangladesh. Further reduction is likely to depend on improved access to qualified community midwives and essential obstetric care at government referral facilities.

Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse.

PubMed

Bain, Luchuo Engelbert; Kongnyuy, Eugene Justine

2018-05-24

The abortion law in Cameroon is highly restrictive. The law permits induced abortions only when the woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest. Unsafe abortions remain rampant with however rare reported cases of persecution, even when these abortions are proven to have been carried out illegally. Available public health interventions are cheap and feasible (Misoprostol and Manual Vacuum Aspiration in post abortion care, modern contraception, post-abortion counseling), and must be implemented to reduce unacceptably high maternal mortality rates in the country which still stand at as high as 596/100.000. Changes in the legal status of abortions might take a long time to come by. Albeit, advocacy efforts must be reinforced to render the law more liberal to permit women to seek safe abortion services. The frequency of abortions, generally clandestine, in this restrictive legal atmosphere has adverse economic, health and social justice implications. We argue that a non-optimal or restrictive legal atmosphere is not an acceptable excuse to justify these high maternal deaths resulting from unsafe abortions, especially in Cameroon where unsafe abortions remain rampant. Implementing currently available, cheap and effective evidence based practice guidelines are possible in the country. Expansion and use of Manual Vacuum Aspiration kits in health care facilities, post-abortion misoprostol and carefully considering the content of post abortion counseling packages deserve keen attention. More large scale qualitative and quantitative studies nationwide to identify and act on context specific barriers to contraception use and abortion related stigma are urgently needed.

Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation.

PubMed

Basinga, Paulin; Gertler, Paul J; Binagwaho, Agnes; Soucat, Agnes L B; Sturdy, Jennifer; Vermeersch, Christel M J

2011-04-23

Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda. 166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics. Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026-0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines. The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health. World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network. Copyright © 2011 Elsevier Ltd. All rights reserved.

Applying human rights to maternal health: UN Technical Guidance on rights-based approaches.

PubMed

Yamin, Alicia Ely

2013-05-01

In the last few years there have been several critical milestones in acknowledging the centrality of human rights to sustainably addressing the scourge of maternal death and morbidity around the world, including from the United Nations Human Rights Council. In 2012, the Council adopted a resolution welcoming a Technical Guidance on rights-based approaches to maternal mortality and morbidity, and calling for a report on its implementation in 2 years. The present paper provides an overview of the contents and significance of the Guidance. It reviews how the Guidance can assist policymakers in improving women's health and their enjoyment of rights by setting out the implications of adopting a human rights-based approach at each step of the policy cycle, from planning and budgeting, to ensuring implementation, to monitoring and evaluation, to fostering accountability mechanisms. The Guidance should also prove useful to clinicians in understanding rights frameworks as applied to maternal health. Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan.

PubMed

Fikree, Fariyal F; Azam, Syed Iqbal; Berendes, Heinz W

2002-01-01

Population-based surveys were conducted in selected clusters of Pakistan's least developed provinces, Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%). Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care.

Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan.

PubMed Central

Fikree, Fariyal F.; Azam, Syed Iqbal; Berendes, Heinz W.

2002-01-01

OBJECTIVE: Population-based surveys were conducted in selected clusters of Pakistan's least developed provinces, Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. METHODS: Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. FINDINGS: The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%). Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. CONCLUSION: The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care. PMID:12075362

The Stillbirth Classification System for the Safe Passage Study: Incorporating Mechanism, Etiology, and Recurrence

PubMed Central

Boyd, Theonia K.; Wright, Colleen A.; Odendaal, Hein J.; Elliott, Amy J.; Sens, Mary Ann; Folkerth, Rebecca D.; Roberts, Drucilla J.; Kinney, Hannah C.

2017-01-01

OBJECTIVE Describe the classification system for the assignment of the cause of death for stillbirth in the Safe Passage Study, an international, multi-institutional, prospective analysis conducted by the NIAAA/NICHD funded PASS Network (The Prenatal Alcohol in SIDS and Stillbirth (PASS) Research Network). The study mission is to determine the role of prenatal alcohol and/or cigarette smoke exposure in adverse pregnancy outcomes, including stillbirth, in a high-risk cohort of 12,000 maternal/fetal dyads. METHODS The PASS Network classification system is based upon 5 ‘sites of origin’ for cause of stillbirth (Fetal, Placental, Maternal, External/Environmental, or Undetermined), further subdivided into mechanism subcategories (e.g., Placental Perfusion Failure). Both site of origin and mechanism stratification are employed to assign an ultimate cause of death. Each PASS stillbirth (n=19) in the feasibility study was assigned a cause of death, and status of sporadic versus recurrent. Adjudication involved review of the maternal and obstetrical records, and fetal autopsy and placental findings, with complete consensus in each case. Two published classification systems, i.e., INCODE and ReCoDe, were used for comparison. RESULTS Causes of stillbirth classified were: fetal (n=5, 26%), placental (n=10, 53%), external (n=1, 5%), and undetermined (n=3, 16%). Nine cases (47%) had placental causes of death due to maternal disorders that carry recurrence risks. There was complete agreement for the cause of death across the three classification systems in 26% of cases, and a combination of partial or complete agreement in 68% of cases. Complete vs. partial agreements were predicated upon the classification schemes used for comparison. CONCLUSIONS The proposed PASS system is a user-friendly classification system that provides comparable information to previously published systems. Advantages include its simplicity, mechanistic formulations, tight clinicopathologic integration, provision for an undetermined category, and its wide applicability for use by perinatal mortality review boards with access to information routinely collected during clinicopathologic evaluations. PMID:27116324

Using the missed opportunity tool as an application of the Lives Saved Tool (LiST) for intervention prioritization.

PubMed

Tam, Yvonne; Pearson, Luwei

2017-11-07

The Missed Opportunity tool was developed as an application in the Lives Saved Tool (LiST) to allow users to quickly compare the relative impact of interventions. Global Financing Facility (GFF) investment cases have been identified as a potential application of the Missed Opportunity analyses in Democratic Republic of the Congo (DRC), Ethiopia, Kenya, and Tanzania, to use 'lives saved' as a normative factor to set priorities. The Missed Opportunity analysis draws on data and methods in LiST to project maternal, stillbirth, and child deaths averted based on changes in interventions' coverage. Coverage of each individual intervention in LiST was automated to be scaled up from current coverage to 90% in the next year, to simulate a scenario where almost every mother and child receive proven interventions that they need. The main outcome of the Missed Opportunity analysis is deaths averted due to each intervention. When reducing unmet need for contraception is included in the analysis, it ranks as the top missed opportunity across the four countries. When it is not included in the analysis, top interventions with the most total deaths averted are hospital-based interventions such as labor and delivery management in the CEmOC and BEmOC level, and full treatment and supportive care for premature babies, and for sepsis/pneumonia. The Missed Opportunity tool can be used to provide a quick, first look at missed opportunities in a country or geographic region, and help identify interventions for prioritization. While it is a useful advocate for evidence-based priority setting, decision makers need to consider other factors that influence decision making, and also discuss how to implement, deliver, and sustain programs to achieve high coverage.

Gender equality as a means to improve maternal and child health in Africa.

PubMed

Singh, Kavita; Bloom, Shelah; Brodish, Paul

2015-01-01

In this article we examine whether measures of gender equality, household decision making, and attitudes toward gender-based violence are associated with maternal and child health outcomes in Africa. We pooled Demographic and Health Surveys data from eight African countries and used multilevel logistic regression on two maternal health outcomes (low body mass index and facility delivery) and two child health outcomes (immunization status and treatment for an acute respiratory infection). We found protective associations between the gender equality measures and the outcomes studied, indicating that gender equality is a potential strategy to improve maternal and child health in Africa.

Gender Equality as a Means to Improve Maternal and Child Health in Africa

PubMed Central

Singh, Kavita; Bloom, Shelah; Brodish, Paul

2015-01-01

In this paper we examine whether measures of gender equality, household decision-making and attitudes toward gender-based violence are associated with maternal and child health outcomes in Africa. We pooled Demographic and Health Surveys (DHS) data from eight African countries and used multilevel logistic regression on two maternal health outcomes (low body mass index and facility delivery) and two child health outcomes (immunization status and treatment for an acute respiratory infection). We found protective associations between the gender equality measures and the outcomes studied, indicating that gender equality is a potential strategy to improve maternal and child health in Africa. PMID:24028632

Case Study: Clinical Governance as an Approach to Improve Maternal and Newborn Health in 22 Hospitals in Indonesia.

PubMed

Amelia, Dwirani; Suhowatsky, Stephanie; Baharuddin, Mohammad; Tholandi, Maya; Hyre, Anne; Sethi, Reena

Clinical governance is a concept used to improve management, accountability and the provision of quality healthcare. An approach to strengthen clinical governance as a means to improve the quality of maternal and newborn care in Indonesia was developed by the Expanding Maternal and Neonatal Survival (EMAS) Program. This case study presents findings and lessons learned from EMAS program experience in 22 hospitals where peer-to-peer mentoring supported staff in strengthening clinical governance from 2012-2015. Efforts resulted in improved hospital preparedness and significantly increased the odds of facility-level coverage for three evidence-based maternal and newborn healthcare interventions.

Intergenerational impacts of maternal mortality: Qualitative findings from rural Malawi

PubMed Central

2015-01-01

Background Maternal mortality, although largely preventable, remains unacceptably high in developing countries such as Malawi and creates a number of intergenerational impacts. Few studies have investigated the far-reaching impacts of maternal death beyond infant survival. This study demonstrates the short- and long-term impacts of maternal death on children, families, and the community in order to raise awareness of the true costs of maternal mortality and poor maternal health care in Neno, a rural and remote district in Malawi. Methods Qualitative in-depth interviews were conducted to assess the impact of maternal mortality on child, family, and community well-being. We conducted 20 key informant interviews, 20 stakeholder interviews, and six sex-stratified focus group discussions in the seven health centers that cover the district. Transcripts were translated, coded, and analyzed in NVivo 10. Results Participants noted a number of far-reaching impacts on orphaned children, their new caretakers, and extended families following a maternal death. Female relatives typically took on caregiving responsibilities for orphaned children, regardless of the accompanying financial hardship and frequent lack of familial or governmental support. Maternal death exacerbated children’s vulnerabilities to long-term health and social impacts related to nutrition, education, employment, early partnership, pregnancy, and caretaking. Impacts were particularly salient for female children who were often forced to take on the majority of the household responsibilities. Participants cited a number of barriers to accessing quality child health care or support services, and many were unaware of programming available to assist them in raising orphaned children or how to access these services. Conclusions In order to both reduce preventable maternal mortality and diminish the impacts on children, extended families, and communities, our findings highlight the importance of financing and implementing universal access to emergency obstetric and neonatal care, and contraception, as well as social protection programs, including among remote populations. PMID:26000733

Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries.

PubMed

Kanyangarara, Mufaro; Chou, Victoria B; Creanga, Andreea A; Walker, Neff

2018-06-01

Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries. We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities "ready to provide obstetric services" had ≥20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services. Of the 111 500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and "ready to provide obstetric services" were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and "ready to provide obstetric services", respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities "ready to provide obstetric services". Relatively higher coverage of facility deliveries (≥65%) and coverage of deliveries in facilities "ready to provide obstetric services" (≥30% of facility deliveries) were only found in three countries. The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care.

Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries

PubMed Central

Kanyangarara, Mufaro; Chou, Victoria B; Creanga, Andreea A; Walker, Neff

2018-01-01

Background Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries. Methods We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities “ready to provide obstetric services” had ≥20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services. Results Of the 111 500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and “ready to provide obstetric services” were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and “ready to provide obstetric services”, respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities “ready to provide obstetric services”. Relatively higher coverage of facility deliveries (≥65%) and coverage of deliveries in facilities “ready to provide obstetric services” (≥30% of facility deliveries) were only found in three countries. Conclusions The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care. PMID:29862026

Health facility service availability and readiness for intrapartum and immediate postpartum care in Malawi: A cross-sectional survey

PubMed Central

Oseni, Lolade; Mtimuni, Angella; Sethi, Reena; Rashidi, Tambudzai; Kachale, Fannie; Rawlins, Barbara; Gupta, Shivam

2017-01-01

This analysis seeks to identify strengths and gaps in the existing facility capacity for intrapartum and immediate postpartum fetal and neonatal care, using data collected as a part of Malawi’s Helping Babies Breath program evaluation. From August to September 2012, the Maternal and Child Health Integrated Program (MCHIP) conducted a cross-sectional survey in 84 Malawian health facilities to capture current health facility service availability and readiness and health worker capacity and practice pertaining to labor, delivery, and immediate postpartum care. The survey collected data on availability of equipment, supplies, and medications, and health worker knowledge and performance scores on intrapartum care simulation and actual management of real clients at a subset of facilities. We ran linear regression models to identify predictors of high simulation performance of routine delivery care and management of asphyxiated newborns across all facilities surveyed. Key supplies for infection prevention and thermal care of the newborn were found to be missing in many of the surveyed facilities. At the health center level, 75% had no clinician trained in basic emergency obstetric care or newborn care and 39% had no midwife trained in the same. We observed that there were no proportional increases in available transport and staff at a facility as catchment population increased. In simulations of management of newborns with breathing problems, health workers were able to complete a median of 10 out of 16 tasks for a full-term birth case scenario and 20 out of 30 tasks for a preterm birth case scenario. Health workers who had more years of experience appeared to perform worse. Our study provides a benchmark and highlights gaps for future evaluations and studies as Malawi continues to make strides in improving facility-based care. Further progress in reducing the burden of neonatal and fetal death in Malawi will be partly predicated on guaranteeing properly equipped and staffed facilities in addition to ensuring the presence of skilled health workers. PMID:28301484

Health facility service availability and readiness for intrapartum and immediate postpartum care in Malawi: A cross-sectional survey.

PubMed

Kozuki, Naoko; Oseni, Lolade; Mtimuni, Angella; Sethi, Reena; Rashidi, Tambudzai; Kachale, Fannie; Rawlins, Barbara; Gupta, Shivam

2017-01-01

This analysis seeks to identify strengths and gaps in the existing facility capacity for intrapartum and immediate postpartum fetal and neonatal care, using data collected as a part of Malawi's Helping Babies Breath program evaluation. From August to September 2012, the Maternal and Child Health Integrated Program (MCHIP) conducted a cross-sectional survey in 84 Malawian health facilities to capture current health facility service availability and readiness and health worker capacity and practice pertaining to labor, delivery, and immediate postpartum care. The survey collected data on availability of equipment, supplies, and medications, and health worker knowledge and performance scores on intrapartum care simulation and actual management of real clients at a subset of facilities. We ran linear regression models to identify predictors of high simulation performance of routine delivery care and management of asphyxiated newborns across all facilities surveyed. Key supplies for infection prevention and thermal care of the newborn were found to be missing in many of the surveyed facilities. At the health center level, 75% had no clinician trained in basic emergency obstetric care or newborn care and 39% had no midwife trained in the same. We observed that there were no proportional increases in available transport and staff at a facility as catchment population increased. In simulations of management of newborns with breathing problems, health workers were able to complete a median of 10 out of 16 tasks for a full-term birth case scenario and 20 out of 30 tasks for a preterm birth case scenario. Health workers who had more years of experience appeared to perform worse. Our study provides a benchmark and highlights gaps for future evaluations and studies as Malawi continues to make strides in improving facility-based care. Further progress in reducing the burden of neonatal and fetal death in Malawi will be partly predicated on guaranteeing properly equipped and staffed facilities in addition to ensuring the presence of skilled health workers.

Developing a network: the PMM process.

PubMed

Kamara, A

1997-11-01

Since 1988, the Prevention of Maternal Mortality (PMM) Network has developed, implemented and evaluated projects that focus directly on prevention of maternal deaths. The Network, which consists of 11 multidisciplinary teams in West Africa and one at Columbia University, grew from discussions between the Carnegie Corporation of New York and researchers at Columbia School of Public Health. Its goals are: to strengthen capacities in developing countries; to provide program models for preventing maternal deaths; and to inform policymakers about the importance of maternal mortality. This paper describes the development and functioning of the Network. The initial steps included identifying interested partners in Africa and encouraging them to form multidisciplinary teams. Each African team received two grants: one to perform a needs assessment and then another to develop and implement projects based on the results. The Columbia team provided technical assistance in a variety of ways, including site visits, workshops and correspondence. Teams tested program models and reported findings both to local policymakers and in international fora. Collaboration with government and community leaders helped facilitate progress at all stages. At the PMM Network Results Conference in 1996, the teams decided to continue their work by forming the Regional PMM (RPMM) Network, an entirely African entity.

Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey.

PubMed

Kenny, Avi; Basu, Gaurab; Ballard, Madeleine; Griffiths, Thomas; Kentoffio, Katherine; Niyonzima, Jean Bosco; Sechler, G Andrew; Selinsky, Stephen; Panjabi, Rajesh R; Siedner, Mark J; Kraemer, John D

2015-12-01

This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post-Ebola health systems reconstruction and for general rural health system planning in sub-Saharan Africa. Cluster-sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS-measured distance from the nearest health facility and the odds of maternal (ANC, facility-based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data. Living in the farthest quartile was associated with lower odds of attending 1-or-more ANC checkup (AOR = 0.04, P < 0.001), 4-or-more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility-based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers. Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized.

Inequality in the use of maternal and child health services in the Philippines: do pro-poor health policies result in more equitable use of services?

PubMed

Paredes, Karlo Paolo P

2016-11-10

The Philippines failed to achieve its Millennium Development Goal (MDG) commitment to reduce maternal deaths by three quarters. This, together with the recently launched Sustainable Development Goals (SDGs), reinforces the need for the country to keep up in improving reach of maternal and child health (MCH) services. Inequitable use of health services is a risk factor for the differences in health outcomes across socio-economic groups. This study aims to explore the extent of inequities in the use of MCH services in the Philippines after pro-poor national health policy reforms. This paper uses data from the 2008 and 2013 Demographic and Health Survey (DHS) in the Philippines. Socio-economic inequality in MCH services use was measured using the concentration index. The concentration index was also decomposed in order to examine the contribution of different factors to the inequalities in the use of MCH services. In absolute figures, women who delivered in facilities increased from 2008 to 2013. Little change was noted for women who received complete antenatal care and caesarean births. Facility deliveries remain pro-rich although a pro-poor shift was noted. Women who received complete antenatal care services also remain concentrated to the rich. Further, there is a highly pro-rich inequality in caesarean deliveries which did not change much from 2008 to 2013. Household income remains as the most important contributor to the resulting inequalities in health services use, followed by maternal education. For complete antenatal care use and deliveries in government facilities, regional differences also showed to have important contribution. The findings suggest inequality in the use of MCH services had limited pro-poor improvements. Household income remains to be the major driver of inequities in MCH services use in the Philippines. This is despite the recent national government-led subsidy for the health insurance of the poor. The highly pro-rich caesarean deliveries may also warrant the need for future studies to determine the prevalence of medically unindicated caesarean births among high-income women. Not applicable.

"Love me, parents!": impact evaluation of a national social and behavioral change communication campaign on maternal health outcomes in Tanzania.

PubMed

Kaufman, Michelle R; Harman, Jennifer J; Smelyanskaya, Marina; Orkis, Jennifer; Ainslie, Robert

2017-09-15

Despite marked improvements over the last few decades, maternal mortality in Tanzania remains among the world's highest at 454 maternal deaths per 100,000 live births. Many factors contribute to this disparity, such as a lack of attendance at antenatal care (ANC) services and low rates of delivery at a health facility with a skilled provider. The Wazazi Nipendeni (Love me, parents) social and behavioral change communication campaign was launched in Tanzania in 2012 to improve a range of maternal health outcomes, including individual birth planning, timely ANC attendance, and giving birth in a healthcare facility. An evaluation to determine the impact of the national Wazazi Nipendeni campaign was conducted in five purposively selected regions of Tanzania using exit interviews with pregnant and post-natal women attending ANC clinics. A total of 1708 women were interviewed regarding campaign exposure, ANC attendance, and individual birth planning. Over one third of interviewed women (35.1%) reported exposure to the campaign in the last month. The more sources from which women reported hearing the Wazazi Nipendeni message, the more they planned for the birth of their child (β = 0.08, p = .001). Greater numbers of types of exposure to the Wazazi Nipendeni message was associated with an increase in ANC visits (β = 0.05, p = .004). Intervention exposure did not significantly predict the timing of the first ANC visit or HIV testing in the adjusted model, however, findings showed that exposure did predict whether women delivered at a health care facility (or not) and whether they tested for HIV with a partner in the unadjusted models. The Wazazi Nipendeni campaign shows promise that such a behavior change communication intervention could lead to better pregnancy and childbirth outcomes for women in low resource settings. For outcomes such as HIV testing, message exposure showed some promising effects, but demographic variables such as age and socioeconomic status appear to be important as well.

Self-reported practices among traditional birth attendants surveyed in western Kenya: a descriptive study.

PubMed

Bucher, Sherri; Konana, Olive; Liechty, Edward; Garces, Ana; Gisore, Peter; Marete, Irene; Tenge, Constance; Shipala, Evelyn; Wright, Linda; Esamai, Fabian

2016-08-12

The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care. A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed. Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs. Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey.

Impact of free delivery policy on utilization of maternal health services in county referral hospitals in Kenya.

PubMed

Njuguna, John; Kamau, Njoroge; Muruka, Charles

2017-06-21

Kenya has a high maternal mortality rate. Provision of skilled delivery plays a major role in reducing maternal mortality. Cost is a hindrance to the utilization of skilled delivery. The Government of Kenya introduced a policy of free delivery services in government facilities beginning June 2013. We sought to determine the impact of this intervention on facility based deliveries in Kenya. We compared deliveries and antenatal attendance in 47 county referral hospitals and 30 low cost private hospitals not participating in the free delivery policy for 2013 and 2014 respectively. The data was extracted from the Kenya Health Information System. Multiple regression was done to assess factors influencing increase in number of deliveries among the county referral hospitals. The number of deliveries and antenatal attendance increased by 26.8% and 16.2% in county referral hospitals and decreased by 11.9% and 5.4% respectively in low cost private hospitals. Increase in deliveries among county referral hospitals was influenced by population size of county and type of county referral hospital. Counties with level 5 hospitals recorded more deliveries compared to those with level 4 hospitals. This intervention increased the number of facility based deliveries. Policy makers may consider incorporating low cost private hospitals so as to increase the coverage of this intervention.

Differential effects of community health worker visits across social and economic groups in Uttar Pradesh, India: a link between social inequities and health disparities.

PubMed

Seth, Aparna; Tomar, Shweta; Singh, Kultar; Chandurkar, Dharmendra; Chakraverty, Amit; Dey, Arnab; Das, Arup K; Hay, Katherine; Saggurti, Niranjan; Boyce, Sabrina; Raj, Anita; Silverman, Jay G

2017-03-07

Uttar Pradesh (UP) accounts for the largest number of neonatal deaths in India. This study explores potential socio-economic inequities in household-level contacts by community health workers (CHWs) and whether the effects of such household-level contacts on receipt of health services differ across populations in this state. A multistage sampling design identified live births in the last 12 months across the 25 highest-risk districts of UP (N = 4912). Regression models described the relations between household demographics (caste, religion, wealth, literacy) and CHW contact, and interactions of demographics and CHW contact in predicting health service utilization (> = 4 antenatal care (ANC) visits, facility delivery, modern contraceptive use). No differences were found in likelihood of CHW contact based on caste, religion, wealth or literacy. Associations of CHW contact with receipt of ANC and facility delivery were significantly affected by religion, wealth and literacy. CHW contact increased the odds of 4 or more ANC visits only among non-Muslim women, increased the odds of both four or more ANC visits and facility delivery only among lower wealth women, increased the odds of facility delivery to a greater degree among illiterate vs. literate women. CHW visits play a vital role in promoting utilization of critical maternal health services in UP. However, significant social inequities exist in associations of CHW visits with such service utilization. Research to clarify these inequities, as well as training for CHWs to address potential biases in the qualities or quantity of their visits based on household socio-economic characteristics is recommended.

Implementation research on community health workers' provision of maternal and child health services in rural Liberia.

PubMed

Luckow, Peter W; Kenny, Avi; White, Emily; Ballard, Madeleine; Dorr, Lorenzo; Erlandson, Kirby; Grant, Benjamin; Johnson, Alice; Lorenzen, Breanna; Mukherjee, Subarna; Ly, E John; McDaniel, Abigail; Nowine, Netus; Sathananthan, Vidiya; Sechler, Gerald A; Kraemer, John D; Siedner, Mark J; Panjabi, Rajesh

2017-02-01

To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.

Implementation research on community health workers’ provision of maternal and child health services in rural Liberia

PubMed Central

Luckow, Peter W; Kenny, Avi; White, Emily; Ballard, Madeleine; Dorr, Lorenzo; Erlandson, Kirby; Grant, Benjamin; Johnson, Alice; Lorenzen, Breanna; Mukherjee, Subarna; Ly, E John; McDaniel, Abigail; Nowine, Netus; Sathananthan, Vidiya; Sechler, Gerald A; Kraemer, John D; Siedner, Mark J

2017-01-01

Abstract Objective To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. Methods The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Findings Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. Conclusion We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes. PMID:28250511

Prioritizing investments in innovations to protect women from the leading causes of maternal death

PubMed Central

2014-01-01

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality. PMID:24405972

Prioritizing investments in innovations to protect women from the leading causes of maternal death.

PubMed

Herrick, Tara M; Harner-Jay, Claudia M; Levisay, Alice M; Coffey, Patricia S; Free, Michael J; LaBarre, Paul D

2014-01-09

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality.

Gestational and Fetal Outcomes in B19 Maternal Infection: a Problem of Diagnosis▿

PubMed Central

Bonvicini, Francesca; Puccetti, Chiara; Salfi, Nunzio C. M.; Guerra, Brunella; Gallinella, Giorgio; Rizzo, Nicola; Zerbini, Marialuisa

2011-01-01

Parvovirus B19 infection during pregnancy is a potential hazard to the fetus because of the virus' ability to infect fetal erythroid precursor cells and fetal tissues. Fetal complications range from transitory fetal anemia and nonimmune fetal hydrops to miscarriage and intrauterine fetal death. In the present study, 72 pregnancies complicated by parvovirus B19 infection were followed up: fetal and neonatal specimens were investigated by serological and/or virological assays to detect fetal/congenital infection, and fetuses and neonates were clinically evaluated to monitor pregnancy outcomes following maternal infection. Analysis of serological and virological maternal B19 markers of infection demonstrated that neither B19 IgM nor B19 DNA detected all maternal infections. IgM serology correctly diagnosed 94.1% of the B19 infections, while DNA testing correctly diagnosed 96.3%. The maximum sensitivity was achieved with the combined detection of both parameters. B19 vertical transmission was observed in 39% of the pregnancies, with an overall 10.2% rate of fetal deaths. The highest rates of congenital infections and B19-related fatal outcomes were observed when maternal infections occurred by the gestational week 20. B19 fetal hydrops occurred in 11.9% of the fetuses, and 28.6% resolved the hydrops with a normal neurodevelopment outcome at 1- to 5-year follow-up. In conclusion, maternal screening based on the concurrent analysis of B19 IgM and DNA should be encouraged to reliably diagnose maternal B19 infection and correctly manage pregnancies at risk. PMID:21849687

High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method.

PubMed

Sharma, Vandana; Brown, Willa; Kainuwa, Muhammad Abdullahi; Leight, Jessica; Nyqvist, Martina Bjorkman

2017-06-02

Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. Interviews with 7,069 women aged 15-49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898-1,126) with a time reference of 2001. Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.

Brought in Dead: An Avoidable Delay in Maternal Deaths.

PubMed

Kumar, Aruna; Agrawal, Neha

2016-10-01

Maternal brought in dead are the patient who dies in the need of adequate medical care. These deaths are often not analyzed sincerely as they are not institutional deaths. Our aim is to find out actual life threatening cause of delay leading to death. Patients brought dead to casualty were seen by the doctors on duty in Department of Obstetrics and Gynaecology,Gandhi Medical College, Bhopal round the clock. Cause of death was analyzed by verbal autopsy of attendants and referral letter from the institute. In this analytical study a complete evaluation of brought deaths from January 2011 to Decmeber 2014 was done. A total of 64 brought in deaths were reported in this 4 year duration. Most common cause of death was postpartum hemorrhage (54.68 %) followed by hypertension (15.62 %) and the most common cause of delay was delay in getting adequate treatment (56.25 %). The brought in dead are the indicator of the three delays in getting health care. Challenges appear to be enormous to be tackled. Timely management proves to be critical in preventing maternal death. Thus it appears that community education about pregnancy and its complications, EmOC training at FRU and strict adherence to referral protocol may help us to reduce the brought dead burden.

Acknowledging HIV and malaria as major causes of maternal mortality in Mozambique

PubMed Central

Singh, Kavita; Moran, Allisyn; Story, William; Bailey, Patricia; Chavane, Leonardo

2014-01-01

Objective To review national data on HIV and malaria as causes of maternal death and to determine the importance of looking at maternal mortality at a subnational level in Mozambique. Methods Three national data surveys were used to document HIV and malaria as causes of maternal mortality and to assess HIV and malaria prevention services for pregnant women. Data were collected between 2007 and 2011, and included population-level verbal autopsy data and household survey data. Results Verbal autopsy data indicated that 18.2% of maternal deaths were due to HIV and 23.1% were due to malaria. Only 19.6% of recently pregnant women received at least two doses of sulfadoxine-pyrimethamine for intermittent preventive treatment, and only 42.3% of pregnant women were sleeping under an insecticide-treated net. Only 37.5% of recently pregnant women had been counseled, tested, and received an HIV test result. Coverage of prevention services varied substantially by province. Conclusion Triangulation of information on cause of death and coverage of interventions can enable appropriate targeting of maternal health interventions. Such information could also help countries in Sub-Saharan Africa to recognize and take action against malaria and HIV in an effort to decrease maternal mortality. PMID:24981974